Provider Demographics
NPI:1114911831
Name:PETERSON, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 W KENT AVE
Mailing Address - Street 2:PO BOX 4907
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-6772
Mailing Address - Country:US
Mailing Address - Phone:406-541-3937
Mailing Address - Fax:406-541-1810
Practice Address - Street 1:700 W KENT AVE
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-6772
Practice Address - Country:US
Practice Address - Phone:406-541-3937
Practice Address - Fax:406-541-1810
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT6492207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT081471Medicaid
MT9763Medicare ID - Type Unspecified
MT081471Medicaid