Basic Information
| Provider Information | |||||||||
| NPI: | 1962464958 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PROKELL | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 816 W CANNON ST | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761043146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173210312 | ||||||||
| FaxNumber: | 8173177033 | ||||||||
| Practice Location | |||||||||
| Address1: | 815 PENNSYLVANIA AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173210312 | ||||||||
| FaxNumber: | 8173177033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2006 | ||||||||
| LastUpdateDate: | 08/15/2012 | ||||||||
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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 | 2085R0202X | K5382 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085B0100X | K5382 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085U0001X | K5382 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2085N0700X | K5382 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology |
ID Information
| ID | Type | State | Issuer | Description | 044833404 | 05 | TX | MEDICAID |