Provider Demographics
NPI:1932295995
Name:PEAVEY, MICHAEL TRISTAN SR (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:TRISTAN
Last Name:PEAVEY
Suffix:SR
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 490
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39649-0490
Mailing Address - Country:US
Mailing Address - Phone:601-250-4366
Mailing Address - Fax:601-250-4367
Practice Address - Street 1:1311 ASTON AVE
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-2825
Practice Address - Country:US
Practice Address - Phone:601-684-2481
Practice Address - Fax:601-684-2488
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14452208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00122130Medicaid
MS00122130Medicaid
MSG46376Medicare UPIN