Healthcare Provider Details

I. General information

NPI: 1811917172
Provider Name (Legal Business Name): ROBERT TODD PETERSEN DC, OPAC, ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 10/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3408 MILTON AVE
DALLAS TX
75205-1338
US

IV. Provider business mailing address

3408 MILTON AVE
DALLAS TX
75205-1338
US

V. Phone/Fax

Practice location:
  • Phone: 214-739-2225
  • Fax: 214-739-2228
Mailing address:
  • Phone: 214-739-2225
  • Fax: 214-739-2228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number9289
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number5118449-1202
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: