Provider Demographics
NPI:1437178985
Name:PETERSON, MICHAEL W (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:W
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 1:2625 E DIVISADERO ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93721-1431
Mailing Address - Country:US
Mailing Address - Phone:559-443-2682
Mailing Address - Fax:559-443-2681
Practice Address - Street 1:2335 E KASHIAN LN STE 260
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93701-2234
Practice Address - Country:US
Practice Address - Phone:559-256-5130
Practice Address - Fax:559-485-4504
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG86406207R00000X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G864060Medicaid
A02433Medicare UPIN
CA00G864060Medicaid