Provider Demographics
NPI:1104936574
Name:PETERS, ROBERT E (PHD, MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:E
Last Name:PETERS
Suffix:
Gender:M
Credentials:PHD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8008 FROST ST
Mailing Address - Street 2:SUITE 304
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4205
Mailing Address - Country:US
Mailing Address - Phone:858-874-0248
Mailing Address - Fax:858-874-0667
Practice Address - Street 1:8008 FROST ST
Practice Address - Street 2:SUITE 304
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4205
Practice Address - Country:US
Practice Address - Phone:858-874-0248
Practice Address - Fax:858-874-0667
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA63776207QA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A637760OtherBLUE SHIELD
CAG92722Medicare UPIN
CA00A637760OtherBLUE SHIELD