Provider Demographics
NPI:1124129754
Name:PETERSON, ROBERT L (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
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 1:6725 SW 29TH ST
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66614-5625
Mailing Address - Country:US
Mailing Address - Phone:785-478-1500
Mailing Address - Fax:785-478-1508
Practice Address - Street 1:6725 SW 29TH ST
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66614-5625
Practice Address - Country:US
Practice Address - Phone:785-478-1500
Practice Address - Fax:785-478-1508
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-12948208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100193590BMedicaid
KS106215OtherMEDICARE PTAN
930043696Medicare ID - Type UnspecifiedRAILROAD MEDICARE
KS100193590BMedicaid
B68617Medicare UPIN
930043696Medicare ID - Type UnspecifiedRAILROAD MEDICARE
001835Medicare ID - Type Unspecified
KS100193590BMedicaid