Healthcare Provider Details

I. General information

NPI: 1649495490
Provider Name (Legal Business Name): ROBERT W. PETZOLD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 02/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 5TH ST
BROOKINGS OR
97415-9702
US

IV. Provider business mailing address

94220 4TH ST
GOLD BEACH OR
97444-7756
US

V. Phone/Fax

Practice location:
  • Phone: 541-412-2000
  • Fax: 541-469-2081
Mailing address:
  • Phone: 541-247-3000
  • Fax: 541-247-3151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD24244
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: