Healthcare Provider Details

I. General information

NPI: 1265403638
Provider Name (Legal Business Name): DALLAS ELWOOD PETERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 06/23/2025
Certification Date: 06/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W CENTRAL TEXAS EXPY STE 117
HARKER HEIGHTS TX
76548-1888
US

IV. Provider business mailing address

300 W CENTRAL TEXAS EXPY STE 117
HARKER HEIGHTS TX
76548-1888
US

V. Phone/Fax

Practice location:
  • Phone: 254-457-4432
  • Fax: 254-618-4941
Mailing address:
  • Phone: 254-457-4432
  • Fax: 254-618-4941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR4764
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number23268
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: