Provider Demographics
NPI:1093717951
Name:PETERSON, ROBERT KAY (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:KAY
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1010 NUT TREE RD
Mailing Address - Street 2:STE 200
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-4172
Mailing Address - Country:US
Mailing Address - Phone:707-624-7900
Mailing Address - Fax:707-624-7911
Practice Address - Street 1:1010 NUT TREE RD
Practice Address - Street 2:STE 200
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687-4172
Practice Address - Country:US
Practice Address - Phone:707-624-7900
Practice Address - Fax:707-624-7901
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG84728207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G50858Medicare UPIN
00G847280Medicare ID - Type Unspecified