Provider Demographics
NPI:1982643680
Name:PETERSON, TRULY (MD)
Entity type:Individual
Prefix:
First Name:TRULY
Middle Name:
Last Name:PETERSON
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 1:5625 EIGER RD STE 200
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78735-8982
Mailing Address - Country:US
Mailing Address - Phone:512-892-7076
Mailing Address - Fax:855-270-9668
Practice Address - Street 1:101 MEDICAL PKWY STE 210
Practice Address - Street 2:
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78738-5647
Practice Address - Country:US
Practice Address - Phone:512-814-1984
Practice Address - Fax:855-270-9668
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM2338207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX181423805Medicaid
TX181423803Medicaid
TX181423804Medicaid
TX181423802Medicaid
TX181423805Medicaid
TXTXB154845Medicare PIN
TXP00432686Medicare PIN
TX181423802Medicaid
TX8J1620Medicare PIN
TX8J9698Medicare PIN