Provider Demographics
NPI:1235100165
Name:PETERSON, ROBERT
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17070 RED OAK DR
Mailing Address - Street 2:SUITE 500
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77090-2619
Mailing Address - Country:US
Mailing Address - Phone:281-893-4144
Mailing Address - Fax:281-583-2375
Practice Address - Street 1:17070 RED OAK DR
Practice Address - Street 2:SUITE 500
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77090-2619
Practice Address - Country:US
Practice Address - Phone:281-893-4144
Practice Address - Fax:281-583-2375
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX206462208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00T009Medicare PIN