Provider Demographics
NPI:1598719916
Name:ROBERT L. PETERSON, INC.
Entity Type:Organization
Organization Name:ROBERT L. PETERSON, INC.
Other - Org Name:ATHENA GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-944-8551
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:808-944-8557
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:808-944-8557
Practice Address - Fax:808-955-5667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD7087208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI91264OtherBLUE CROSS BLUE SHEILD
HI91264Medicaid
HIMD7087OtherQUEENS HEALTH CARE
E45988Medicare UPIN
HI0000BDTFHMedicare ID - Type Unspecified