Provider Demographics
NPI:1407905524
Name:PETERSON, ROBERT L (MD)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:L
Last Name:PETERSON
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 1:1319 PUNAHOU ST
Mailing Address - Street 2:1070
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96826-1001
Mailing Address - Country:US
Mailing Address - Phone:808-944-8551
Mailing Address - Fax:808-955-5667
Practice Address - Street 1:1319 PUNAHOU ST
Practice Address - Street 2:1070
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96826-1001
Practice Address - Country:US
Practice Address - Phone:808-944-8551
Practice Address - Fax:808-955-5667
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2008-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD7087208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI91264OtherBLUE CROSS BLUE SHIELD HI
HI0000BDTFHMedicare ID - Type Unspecified
HI91264OtherBLUE CROSS BLUE SHIELD HI