Provider Demographics
NPI:1902806482
Name:PAEK, DONALD R SR (MD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:R
Last Name:PAEK
Suffix:SR
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 1:5701 BRYANT IRVIN RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-4029
Mailing Address - Country:US
Mailing Address - Phone:817-294-4184
Mailing Address - Fax:817-294-4198
Practice Address - Street 1:5701 BRYANT IRVIN RD
Practice Address - Street 2:SUITE 102
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4029
Practice Address - Country:US
Practice Address - Phone:817-294-4184
Practice Address - Fax:817-294-4198
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-27
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXGA188207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00AQ90Medicare ID - Type Unspecified
B25348Medicare UPIN