Healthcare Provider Details

I. General information

NPI: 1619138450
Provider Name (Legal Business Name): ROBERT D PETRIE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2008
Last Update Date: 09/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78822 HIGHWAY 111
LA QUINTA CA
92253-2046
US

IV. Provider business mailing address

80090 CALDER DR
INDIO CA
92203-4849
US

V. Phone/Fax

Practice location:
  • Phone: 760-777-7701
  • Fax:
Mailing address:
  • Phone: 760-238-0501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License NumberC50893
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: