Provider Demographics
NPI:1669865424
Name:PETERSON, ROBERT (DO)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1045 W REDONDO BEACH BLVD FL 3
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-4128
Mailing Address - Country:US
Mailing Address - Phone:323-241-6730
Mailing Address - Fax:
Practice Address - Street 1:1045 W REDONDO BEACH BLVD FL 3
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-4128
Practice Address - Country:US
Practice Address - Phone:323-241-6730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-17
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A143812084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry