Provider Demographics
NPI:1265403638
Name:PETERSON, DALLAS ELWOOD (MD)
Entity type:Individual
Prefix:
First Name:DALLAS
Middle Name:ELWOOD
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W CENTRAL TEXAS EXPY STE 117
Mailing Address - Street 2:
Mailing Address - City:HARKER HEIGHTS
Mailing Address - State:TX
Mailing Address - Zip Code:76548-1888
Mailing Address - Country:US
Mailing Address - Phone:254-457-4432
Mailing Address - Fax:254-618-4941
Practice Address - Street 1:300 W CENTRAL TEXAS EXPY STE 117
Practice Address - Street 2:
Practice Address - City:HARKER HEIGHTS
Practice Address - State:TX
Practice Address - Zip Code:76548-1888
Practice Address - Country:US
Practice Address - Phone:254-457-4432
Practice Address - Fax:254-618-4941
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR4764207Q00000X
AZ23268207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ315441Medicaid
AZ315441Medicaid
AZ08WCLDG03Medicare PIN