Healthcare Provider Details

I. General information

NPI: 1104936574
Provider Name (Legal Business Name): ROBERT E PETERS PHD, M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 11/05/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8008 FROST ST SUITE 304
SAN DIEGO CA
92123-4205
US

IV. Provider business mailing address

8008 FROST ST SUITE 304
SAN DIEGO CA
92123-4205
US

V. Phone/Fax

Practice location:
  • Phone: 858-874-0248
  • Fax: 858-874-0667
Mailing address:
  • Phone: 858-874-0248
  • Fax: 858-874-0667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License NumberA63776
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: