Basic Information
| Provider Information | |||||||||
| NPI: | 1912385931 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | GREGORY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3500 GASTON AVE | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752462017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2148200111 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3500 GASTON AVE | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752462017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2148200111 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2015 | ||||||||
| LastUpdateDate: | 06/13/2016 | ||||||||
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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 | BP10052636 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207N00000X | BP20055598 | TX | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.