Provider Demographics
NPI:1437137288
Name:PEASTER, MICHAEL LEON (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LEON
Last Name:PEASTER
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 1:500 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74003-3909
Mailing Address - Country:US
Mailing Address - Phone:918-338-3800
Mailing Address - Fax:918-336-1505
Practice Address - Street 1:500 E 5TH ST
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74003-3909
Practice Address - Country:US
Practice Address - Phone:918-338-3800
Practice Address - Fax:918-336-1505
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23383208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200010690Medicaid
F11831Medicare UPIN
OK200010690Medicaid