Provider Demographics
NPI:1881122513
Name:THEISS, PETER (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:THEISS
Suffix:
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 1:252 MATLOCK RD STE 234
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-6565
Mailing Address - Country:US
Mailing Address - Phone:214-948-2076
Mailing Address - Fax:214-948-9990
Practice Address - Street 1:252 MATLOCK RD STE 234
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-6565
Practice Address - Country:US
Practice Address - Phone:214-948-2076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-25
Last Update Date:2025-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036152108207T00000X
390200000X
TXV9427207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program