Provider Demographics
NPI:1467428656
Name:PETERSEN, MICHAEL S (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:PETERSEN
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 1:10470 OLD PLACERVILLE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:2020 SUTTER PL
Practice Address - Street 2:SUITE 104
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-6213
Practice Address - Country:US
Practice Address - Phone:530-750-5900
Practice Address - Fax:530-750-5901
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-27
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA49302207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA200018048OtherRAILROAD MEDICARE INDIVIDUAL PTAN
CA200018048OtherRAILROAD MEDICARE INDIVIDUAL PTAN
CAC67926Medicare UPIN
0398360001Medicare NSC