Healthcare Provider Details

I. General information

NPI: 1376121483
Provider Name (Legal Business Name): STEFAN PETERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2021
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2750 W NORTHWEST HWY STE 170
DALLAS TX
75220-4783
US

IV. Provider business mailing address

27700 NORTHWEST FWY STE 440
CYPRESS TX
77433-6767
US

V. Phone/Fax

Practice location:
  • Phone: 214-654-0007
  • Fax:
Mailing address:
  • Phone: 832-334-4011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberV1585
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: