Provider Demographics
NPI:1881649978
Name:PETERSON, ROBERT L (MD)
Entity Type:Individual
Prefix:
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:PO BOX 38
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28603-0038
Mailing Address - Country:US
Mailing Address - Phone:828-322-4140
Mailing Address - Fax:828-322-3767
Practice Address - Street 1:1501 TATE BLVD SE
Practice Address - Street 2:SUITE 201
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602-4243
Practice Address - Country:US
Practice Address - Phone:828-322-4140
Practice Address - Fax:828-322-3767
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21503207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8967216Medicaid
NC2280823AMedicare ID - Type Unspecified
NCC82084Medicare UPIN