Provider Demographics
NPI:1356577787
Name:OBESSO, PETER DANIEL (DO)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:DANIEL
Last Name:OBESSO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:120 E CHARNWOOD ST
Practice Address - Street 2:SUITE B
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1708
Practice Address - Country:US
Practice Address - Phone:903-525-1664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-29
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP7011207RS0012X
FLOS11800207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX752616977028OtherTRICARE
TX752616977002OtherTRICARE
TX752616977001OtherTRICARE
TXP01246236OtherRAIL ROAD
TX323899001Medicaid
TX75-2616977-120OtherTRICARE
TX752616977015OtherTRICARE
TXP01246236OtherRAIL ROAD