=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457430050
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PETER C SOO MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2006
-----------------------------------------------------
Last Update Date | 04/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3000 POLAR LN STE 101
-----------------------------------------------------
City | CEDAR PARK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78613-3065
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-824-8775
-----------------------------------------------------
Fax | 281-648-2200
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 205 E UNIVERSITY AVE STE 200
-----------------------------------------------------
City | GEORGETOWN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78626-6821
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-800-5722
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | K0383
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------