Provider Demographics
NPI:1073503819
Name:PFEFFER, ROBERT I(SA) (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:I(SA)
Last Name:PFEFFER
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 1:3323 W GLOUCESTER CT
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-2601
Mailing Address - Country:US
Mailing Address - Phone:309-692-5462
Mailing Address - Fax:
Practice Address - Street 1:3323 W GLOUCESTER CT
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-2601
Practice Address - Country:US
Practice Address - Phone:309-692-5462
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG196382084N0400X
OH0299182084N0400X
CO167972084N0400X
IL2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAP 5008392OtherDEA #
CAA40710Medicare UPIN
CAG 019638Medicare ID - Type UnspecifiedCA LIC, MCARE W OR W/O 0