Basic Information
Provider Information | |||||||||
NPI: | 1518027366 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PETERSON | ||||||||
FirstName: | DANIEL | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 801 W 38TH ST | ||||||||
Address2: | SUITE 400 | ||||||||
City: | AUSTIN | ||||||||
State: | TX | ||||||||
PostalCode: | 787051167 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5123061323 | ||||||||
FaxNumber: | 5123061142 | ||||||||
Practice Location | |||||||||
Address1: | 801 W 38TH ST | ||||||||
Address2: | SUITE 400 | ||||||||
City: | AUSTIN | ||||||||
State: | TX | ||||||||
PostalCode: | 787051167 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5123061323 | ||||||||
FaxNumber: | 5123061142 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/11/2006 | ||||||||
LastUpdateDate: | 07/24/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | J6207 | TX | Y |   | Allopathic & Osteopathic Physicians | Neurological Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 4599570 | 01 | TX | AETNA | OTHER | 120619503 | 01 | TX | TPI | OTHER | P000N72D6 | 05 | TX |   | MEDICAID | 140005923 | 01 | TX | MEDICARE RAILROAD | OTHER | 89732F | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER |