Provider Demographics
NPI:1457430050
Name:SOO, PETER C (MD)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:C
Last Name:SOO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:PETER
Other - Middle Name:C
Other - Last Name:SOO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD PA
Mailing Address - Street 1:205 E UNIVERSITY AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-6821
Mailing Address - Country:US
Mailing Address - Phone:877-800-5722
Mailing Address - Fax:
Practice Address - Street 1:2423 WILLIAMS DR STE 108
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-3269
Practice Address - Country:US
Practice Address - Phone:877-800-5722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK03832084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0082KCOtherBCBS OF TX
7982417OtherAETNA
TX0082KCOtherBCBS OF TX