Provider Demographics
NPI:1700230612
Name:PETRIE, ROBERT JR (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:PETRIE
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6100 LAKE WORTH BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76135-3703
Mailing Address - Country:US
Mailing Address - Phone:817-237-3321
Mailing Address - Fax:817-237-7970
Practice Address - Street 1:6100 LAKE WORTH BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-3703
Practice Address - Country:US
Practice Address - Phone:817-237-3321
Practice Address - Fax:817-237-7970
Is Sole Proprietor?:No
Enumeration Date:2016-04-17
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS0058207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine