Provider Demographics
NPI:1134790090
Name:PETERSON, MICHAEL GUSTAVO
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GUSTAVO
Last Name:PETERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:718 4TH ST
Mailing Address - Street 2:
Mailing Address - City:GOTHENBURG
Mailing Address - State:NE
Mailing Address - Zip Code:69138-2347
Mailing Address - Country:US
Mailing Address - Phone:308-537-2048
Mailing Address - Fax:308-537-2231
Practice Address - Street 1:718 4TH ST
Practice Address - Street 2:
Practice Address - City:GOTHENBURG
Practice Address - State:NE
Practice Address - Zip Code:69138-2347
Practice Address - Country:US
Practice Address - Phone:308-537-2048
Practice Address - Fax:308-537-2231
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-01
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE805333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy