Provider Demographics
NPI:1174579874
Name:PETERSON, DARRYL W (MD)
Entity type:Individual
Prefix:MR
First Name:DARRYL
Middle Name:W
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2800 S TEXAS AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-5361
Mailing Address - Country:US
Mailing Address - Phone:979-774-2061
Mailing Address - Fax:979-776-5914
Practice Address - Street 1:2803 EARL RUDDER FWY S STE 202
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-6099
Practice Address - Country:US
Practice Address - Phone:979-731-8888
Practice Address - Fax:979-731-8935
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK3391207XS0106X, 207X00000X
LA12182R207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1543365Medicaid
TX370416501Medicaid
LA1543365Medicaid
TX370416501Medicaid