Provider Demographics
NPI:1316941123
Name:PETERS, WALTER RUSSELL JR (MD, MBA)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:RUSSELL
Last Name:PETERS
Suffix:JR
Gender:M
Credentials:MD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3409 WORTH ST
Mailing Address - Street 2:WORTH TOWER, SUITE 640
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-2029
Mailing Address - Country:US
Mailing Address - Phone:469-800-7180
Mailing Address - Fax:469-800-7190
Practice Address - Street 1:3409 WORTH ST
Practice Address - Street 2:WORTH TOWER, SUITE 640
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-2029
Practice Address - Country:US
Practice Address - Phone:469-800-7180
Practice Address - Fax:469-800-7190
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR6G45208600000X, 208C00000X
TXQ6358208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1284609OtherUNITED HEALTHCARE
MO123497OtherPHCS
MO28058OtherGHP
MO5125OtherHEALTHCARE USA
TX8FM794OtherBCBS
MO25055OtherANTHEM BLUECROSS BLUESHIE
TX3548646-01Medicaid
MO4343317OtherAETNA
TX4343317OtherAETNA
MO431428562OtherGREAT WEST
TX1316941123OtherNPI
MO202523015Medicaid
MOA10787OtherMERCY
MO5125OtherHEALTHCARE USA
MO202523015Medicaid
MO330001698Medicare PIN
MO431428562OtherGREAT WEST
TX8FM794OtherBCBS