Healthcare Provider Details

I. General information

NPI: 1578060182
Provider Name (Legal Business Name): PETER MICHAEL KARAGOZIAN III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2018
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8591 S BROADWAY AVE
TYLER TX
75703-5470
US

IV. Provider business mailing address

8591 S BROADWAY AVE
TYLER TX
75703-5470
US

V. Phone/Fax

Practice location:
  • Phone: 903-596-9173
  • Fax:
Mailing address:
  • Phone: 903-593-9173
  • Fax: 903-592-1684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberS5944
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: