Provider Demographics
NPI:1356803530
Name:PECKHAM FOSTER, ELISSA JANELLE (DO)
Entity type:Individual
Prefix:DR
First Name:ELISSA
Middle Name:JANELLE
Last Name:PECKHAM FOSTER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:ELISSA
Other - Middle Name:J
Other - Last Name:PECKHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1505 LYNDON B JOHNSON FWY STE 700
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75234-6065
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1250 8TH AVE STE 135
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4156
Practice Address - Country:US
Practice Address - Phone:214-358-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-05
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXU9522207RN0300X, 207RN0300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU9522OtherMEDICAL LICENCE