Healthcare Provider Details

I. General information

NPI: 1952304776
Provider Name (Legal Business Name): PETER MILDER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 10/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2108 TEXAS AVE SUITE 3080
ALEXANDRIA LA
71301-3944
US

IV. Provider business mailing address

919 HIDDEN RDG
IRVING TX
75038-3813
US

V. Phone/Fax

Practice location:
  • Phone: 318-442-5758
  • Fax: 318-445-7210
Mailing address:
  • Phone: 469-282-2711
  • Fax: 469-282-0995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number10168R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: