Provider Demographics
NPI:1720007834
Name:CHRISTENSEN, PETER (DO)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:CHRISTENSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 WASHINGTON AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-7724
Mailing Address - Country:US
Mailing Address - Phone:616-392-8035
Mailing Address - Fax:
Practice Address - Street 1:904 WASHINGTON AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-7724
Practice Address - Country:US
Practice Address - Phone:616-392-8035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101015100207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4605400Medicaid
MI4605400Medicaid
0H06000046Medicare ID - Type Unspecified