Provider Demographics
NPI:1124076062
Name:PETERS, BRIAN ROBERT (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:ROBERT
Last Name:PETERS
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 1:7777 FOREST LN
Mailing Address - Street 2:A-103
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-2505
Mailing Address - Country:US
Mailing Address - Phone:972-566-7600
Mailing Address - Fax:972-566-6560
Practice Address - Street 1:7777 FOREST LN
Practice Address - Street 2:A-103
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2505
Practice Address - Country:US
Practice Address - Phone:972-566-7600
Practice Address - Fax:972-566-6560
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG5473207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX872112OtherBCBS
VT1012398Medicaid
TX872112Medicare ID - Type UnspecifiedMEDICARE ID
VT1012398Medicaid
TX872112OtherBCBS