Basic Information
| Provider Information | |||||||||
| NPI: | 1225128259 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PITONAK | ||||||||
| FirstName: | PETER | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 846098 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752846098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033246450 | ||||||||
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| Practice Location | |||||||||
| Address1: | 703 E FLEISHEL AVE | ||||||||
| Address2: | STE 4000 | ||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757012015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036067000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 05/05/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 00024770 | AL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | M9934 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 110248812 | 01 | AL | RAILROAD MEDICARE | OTHER | 75-2616977-132 | 01 | TX | TRICARE | OTHER | 051511035 | 05 | AL | MEDICAID | 51511035 | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER |