Provider Demographics
NPI:1548312382
Name:PETERSON, TIMOTHY W (DC)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:W
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4230 GARDENDALE
Mailing Address - Street 2:BLDG 201
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229
Mailing Address - Country:US
Mailing Address - Phone:210-691-2747
Mailing Address - Fax:
Practice Address - Street 1:4230 GARDENDALE ST
Practice Address - Street 2:BLDG 201
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3475
Practice Address - Country:US
Practice Address - Phone:210-691-2747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7180111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor