Provider Demographics
NPI:1649495490
Name:PETZOLD, ROBERT W (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:PETZOLD
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 1:94220 4TH ST
Mailing Address - Street 2:
Mailing Address - City:GOLD BEACH
Mailing Address - State:OR
Mailing Address - Zip Code:97444-7756
Mailing Address - Country:US
Mailing Address - Phone:541-247-3000
Mailing Address - Fax:541-247-3151
Practice Address - Street 1:500 5TH ST
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415-9702
Practice Address - Country:US
Practice Address - Phone:541-412-2000
Practice Address - Fax:541-469-2081
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD24244207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR231907Medicaid
OR115480Medicare ID - Type Unspecified
OR231907Medicaid