Healthcare Provider Details

I. General information

NPI: 1174547608
Provider Name (Legal Business Name): PETER UNTALAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 06/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 NORTH IH-35 SUITE 770
AUSTIN TX
78705
US

IV. Provider business mailing address

3000 NORTH IH-35 SUITE 770
AUSTIN TX
78705
US

V. Phone/Fax

Practice location:
  • Phone: 512-482-8880
  • Fax: 512-476-0467
Mailing address:
  • Phone: 512-482-8880
  • Fax: 512-476-0467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberK7930
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberK7930
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: