Provider Demographics
NPI:1578651923
Name:PETERSON, MICHAEL THEODORE (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:THEODORE
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:PO BOX 366
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-0366
Mailing Address - Country:US
Mailing Address - Phone:541-758-5047
Mailing Address - Fax:541-758-3713
Practice Address - Street 1:930 SW ABBEY ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-4820
Practice Address - Country:US
Practice Address - Phone:541-754-4710
Practice Address - Fax:541-574-2858
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD093752085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR279000Medicaid
ORC93521Medicare UPIN
OR279000Medicaid