Provider Demographics
NPI:1982715439
Name:PETERSON, PERRY HERMAN (DPM)
Entity Type:Individual
Prefix:DR
First Name:PERRY
Middle Name:HERMAN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 COUNTY ROAD 144B
Mailing Address - Street 2:
Mailing Address - City:MARBLE FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:78654-8020
Mailing Address - Country:US
Mailing Address - Phone:830-798-8314
Mailing Address - Fax:
Practice Address - Street 1:325 COUNTY ROAD 144B
Practice Address - Street 2:
Practice Address - City:MARBLE FALLS
Practice Address - State:TX
Practice Address - Zip Code:78654-8020
Practice Address - Country:US
Practice Address - Phone:830-798-8314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2014-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0567213E00000X, 213EP0504X, 213EP1101X, 213ES0000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP0504XPodiatric Medicine & Surgery Service ProvidersPodiatristPublic Medicine
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0008138-01Medicaid
TX00AM35OtherBLUE CROSS BLUE SHIELD
TXT15267Medicare UPIN
TX5016670001Medicare NSC
TX0008138-01Medicaid