Healthcare Provider Details

I. General information

NPI: 1558786723
Provider Name (Legal Business Name): KURT ROBERT PETERSON D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2014
Last Update Date: 09/17/2021
Certification Date: 09/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5320 S RAINBOW BLVD STE 300
LAS VEGAS NV
89118-1896
US

IV. Provider business mailing address

5320 S RAINBOW BLVD STE 300
LAS VEGAS NV
89118-1896
US

V. Phone/Fax

Practice location:
  • Phone: 702-892-9666
  • Fax:
Mailing address:
  • Phone: 702-892-9666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License NumberDO2840
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: