Provider Demographics
NPI:1750359915
Name:VASCONCELLOS, PETER (DO)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:VASCONCELLOS
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 1:15118 AQUARIUS ST
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78418-6903
Mailing Address - Country:US
Mailing Address - Phone:361-800-5917
Mailing Address - Fax:
Practice Address - Street 1:15118 AQUARIUS ST
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78418-6903
Practice Address - Country:US
Practice Address - Phone:361-800-5917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA3288207Q00000X
TXN9792207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1205666Medicaid
IA1205666Medicaid
I6635Medicare PIN