Provider Demographics
NPI:1285999185
Name:PETERSEN, PAMELA CAROL (MD)
Entity type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:CAROL
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6651 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2351
Mailing Address - Country:US
Mailing Address - Phone:832-826-4431
Mailing Address - Fax:
Practice Address - Street 1:6651 MAIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030
Practice Address - Country:US
Practice Address - Phone:832-826-4431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-07
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI63560-20208000000X
TXR75632080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics