Healthcare Provider Details

I. General information

NPI: 1982715439
Provider Name (Legal Business Name): PERRY HERMAN PETERSON D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 11/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 COUNTY ROAD 144B
MARBLE FALLS TX
78654-8020
US

IV. Provider business mailing address

325 COUNTY ROAD 144B
MARBLE FALLS TX
78654-8020
US

V. Phone/Fax

Practice location:
  • Phone: 830-798-8314
  • Fax:
Mailing address:
  • Phone: 830-798-8314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number0567
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code213EP0504X
TaxonomyPublic Medicine Podiatrist
License Number0567
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number0567
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License Number0567
License Number StateTX
# 5
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number0567
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: