Provider Demographics
NPI:1013934447
Name:PETERS, MICHELLE C (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:C
Last Name:PETERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 W PARADISE DR
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-9795
Mailing Address - Country:US
Mailing Address - Phone:262-334-3451
Mailing Address - Fax:
Practice Address - Street 1:1700 W PARADISE DR
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-9795
Practice Address - Country:US
Practice Address - Phone:262-334-3451
Practice Address - Fax:262-347-3044
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI46999207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34560200Medicaid
WI021307650Medicare ID - Type Unspecified
WI34560200Medicaid