Provider Demographics
NPI:1720144876
Name:PETERSON, ROBERT LESTER (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:LESTER
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 1:900 RIVERSIDE DR
Mailing Address - Street 2:SUITE III
Mailing Address - City:WAUPACA
Mailing Address - State:WI
Mailing Address - Zip Code:54981-1983
Mailing Address - Country:US
Mailing Address - Phone:715-258-8898
Mailing Address - Fax:715-258-6980
Practice Address - Street 1:900 RIVERSIDE DR
Practice Address - Street 2:SUITE III
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-1983
Practice Address - Country:US
Practice Address - Phone:715-258-8898
Practice Address - Fax:715-258-6980
Is Sole Proprietor?:No
Enumeration Date:2006-12-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19601207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI19601OtherLICENSE
WI31229100Medicaid
B55715Medicare UPIN
69019Medicare ID - Type Unspecified