Provider Demographics
NPI:1952444234
Name:PETERS, JANA MICHELLE (DO)
Entity Type:Individual
Prefix:
First Name:JANA
Middle Name:MICHELLE
Last Name:PETERS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 COURTHOUSE ROAD
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740
Mailing Address - Country:US
Mailing Address - Phone:304-425-3922
Mailing Address - Fax:304-487-0229
Practice Address - Street 1:365 COURTHOUSE ROAD
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740
Practice Address - Country:US
Practice Address - Phone:304-425-3922
Practice Address - Fax:304-487-0229
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV963207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001720753OtherMT STATE BCBS
WV0041701001Medicaid
WV0041701001Medicaid
C35062Medicare UPIN