Provider Demographics
NPI:1891852638
Name:PETERSON, ROBERT GOODLOE (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:GOODLOE
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:680 PARKWOOD MEDICAL PARK
Mailing Address - Street 2:
Mailing Address - City:ELKIN
Mailing Address - State:NC
Mailing Address - Zip Code:28621-2487
Mailing Address - Country:US
Mailing Address - Phone:336-835-7208
Mailing Address - Fax:336-835-7209
Practice Address - Street 1:680 PARKWOOD MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:ELKIN
Practice Address - State:NC
Practice Address - Zip Code:28621-2487
Practice Address - Country:US
Practice Address - Phone:336-835-7208
Practice Address - Fax:336-835-7209
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23070208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCC85969Medicare UPIN