Provider Demographics
NPI:1366562696
Name:FADOW, PETER G (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:G
Last Name:FADOW
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 1:4730 COLLEGE DR
Mailing Address - Street 2:6515 KEMP BLVD, WICHITA FALLS, TX 76308
Mailing Address - City:VERNON
Mailing Address - State:TX
Mailing Address - Zip Code:76384-4009
Mailing Address - Country:US
Mailing Address - Phone:940-552-9901
Mailing Address - Fax:
Practice Address - Street 1:4730 COLLEGE DR
Practice Address - Street 2:6515 KEMP BLVD, WICHITA FALLS, TX 76308
Practice Address - City:VERNON
Practice Address - State:TX
Practice Address - Zip Code:76384-4009
Practice Address - Country:US
Practice Address - Phone:940-552-9901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ7951283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX85G545Medicare ID - Type Unspecified
TXF73233Medicare UPIN