Provider Demographics
NPI:1962403717
Name:DOTTERRER, ROBERT M (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:M
Last Name:DOTTERRER
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 1:6609 PENINSULA DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-1737
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6609 PENINSULA DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-1737
Practice Address - Country:US
Practice Address - Phone:231-935-2191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301050243208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0202810041OtherBLUE CARE NETWORK
MI1930282Medicaid
MIB86018144OtherMUNSON MEDICARE PIN
MI382991220OtherHEALTH NET/TRICARE
MI0202810041OtherBCBS
MIB46660OtherPRIORITY
MI1962403717OtherROBERT M DOTTERRER MD
MIB86018144OtherMUNSON MEDICARE PIN
MI020015688Medicare PIN
MI382991220OtherHEALTH NET/TRICARE