Provider Demographics
NPI:1104922491
Name:PETERSON, ROBERT G (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:G
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 1:42125 CALLE LAGARTIJA
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-7504
Mailing Address - Country:US
Mailing Address - Phone:951-676-5541
Mailing Address - Fax:
Practice Address - Street 1:42125 CALLE LAGARTIJA
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-7504
Practice Address - Country:US
Practice Address - Phone:951-676-5541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG045382207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G453820Medicare PIN