Provider Demographics
NPI:1306839766
Name:PETERS, MICHAEL (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:PETERS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7100 SIX FORKS RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-6156
Mailing Address - Country:US
Mailing Address - Phone:919-847-0187
Mailing Address - Fax:919-676-2231
Practice Address - Street 1:14460 NEW FALLS OF NEUSE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27614-8227
Practice Address - Country:US
Practice Address - Phone:919-847-4665
Practice Address - Fax:919-488-4668
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1304152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890926WMedicaid
NC0926WOtherBLUECROSS
NC410048136OtherRAILROAD MEDICARE
NC246599NMedicare PIN
NCT65111Medicare UPIN