Healthcare Provider Details

I. General information

NPI: 1710987813
Provider Name (Legal Business Name): ROBERT W PEDERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 12/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 E BUENA VISTA ST
SANTA FE NM
87505-2621
US

IV. Provider business mailing address

207 E BUENA VISTA ST
SANTA FE NM
87505-2621
US

V. Phone/Fax

Practice location:
  • Phone: 512-970-3666
  • Fax:
Mailing address:
  • Phone: 512-970-3666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberE1920
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberE1920
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: