Provider Demographics
NPI:1831174093
Name:PETERSON, ROBERT D (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:D
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:PO BOX 1969
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86405-1969
Mailing Address - Country:US
Mailing Address - Phone:928-680-3343
Mailing Address - Fax:928-680-3342
Practice Address - Street 1:2035 MESQUITE AVE
Practice Address - Street 2:SUITE C
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5894
Practice Address - Country:US
Practice Address - Phone:928-680-3343
Practice Address - Fax:928-680-3342
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-09
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ48485207R00000X
TNMD 269312083A0100X, 207R00000X
WA60079305207R00000X
ORMD27081207R00000X, 207RH0000X
TNMD 26931207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B45561Medicare UPIN
WA1831174093Medicare UPIN
WAG8882298Medicare PIN
OR38-1852Medicare ID - Type UnspecifiedCOASTAL FHC
WA1831174093Medicare UPIN
TN3092937Medicare ID - Type Unspecified
B45561Medicare UPIN