Provider Demographics
NPI:1306880786
Name:PEET, JASON N (MD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:N
Last Name:PEET
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 1:110 E. LIVE OAK ST.
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78624-4450
Mailing Address - Country:US
Mailing Address - Phone:830-997-5559
Mailing Address - Fax:830-997-5558
Practice Address - Street 1:110 E. LIVE OAK ST.
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:TX
Practice Address - Zip Code:78624-4450
Practice Address - Country:US
Practice Address - Phone:830-997-5559
Practice Address - Fax:830-997-5558
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7861207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX105369603Medicaid
TXH11777Medicare UPIN
TX8464M2Medicare ID - Type Unspecified