Provider Demographics
NPI:1225395361
Name:PETERS, NICHOLAS J (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:J
Last Name:PETERS
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 1:1134 N MAIN ST STE 3100
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTAINE
Mailing Address - State:OH
Mailing Address - Zip Code:43311-2379
Mailing Address - Country:US
Mailing Address - Phone:937-651-6441
Mailing Address - Fax:937-651-6442
Practice Address - Street 1:1134 N MAIN ST STE 3100
Practice Address - Street 2:
Practice Address - City:BELLEFONTAINE
Practice Address - State:OH
Practice Address - Zip Code:43311-2379
Practice Address - Country:US
Practice Address - Phone:937-651-6441
Practice Address - Fax:937-651-6442
Is Sole Proprietor?:No
Enumeration Date:2012-04-13
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.132291207XX0005X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0281123Medicaid