MEDICARE: DR. ROBERT TODD PETERSEN DC, OPAC, ATC, LAT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant		TX
2	111NS0005X	Sports Physician Chiropractor	9289	TX
3	111NS0005X	Sports Physician Chiropractor	5118449-1202	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	607194	OTHER	TX	BCBS ID NUMBER

General Provider Information

NPI Number	:	1811917172
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERT TODD PETERSEN DC, OPAC, ATC, LAT

Provider Business Mailing Address
First Line	:	3408 MILTON AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75205-1338
Country	:	US
Telephone Number	:	214-739-2225
Fax Number	:	214-739-2228

Provider Business Practice Location Address
First Line	:	3408 MILTON AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75205-1338
Country	:	US
Telephone Number	:	214-739-2225
Fax Number	:	214-739-2228

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2006
Last Update Date	:	10/30/2014

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Directions to “ DR. ROBERT TODD PETERSEN DC, OPAC, ATC, LAT” Practice Location

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