Provider Demographics
NPI:1811917172
Name:PETERSEN, ROBERT TODD (DC, OPAC, ATC, LAT)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:TODD
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:DC, OPAC, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3408 MILTON AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75205-1338
Mailing Address - Country:US
Mailing Address - Phone:214-739-2225
Mailing Address - Fax:214-739-2228
Practice Address - Street 1:3408 MILTON AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75205-1338
Practice Address - Country:US
Practice Address - Phone:214-739-2225
Practice Address - Fax:214-739-2228
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363A00000X
TX9289111NS0005X
UT5118449-1202111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX607194OtherBCBS ID NUMBER