Provider Demographics
NPI:1255419024
Name:PETERSON, MICHAEL BLAIR (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BLAIR
Last Name:PETERSON
Suffix:
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 1:1320 EL CAPITAN DR
Mailing Address - Street 2:STE 120
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94526-6260
Mailing Address - Country:US
Mailing Address - Phone:925-334-5800
Mailing Address - Fax:925-689-3102
Practice Address - Street 1:2500 MERCED ST
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-4201
Practice Address - Country:US
Practice Address - Phone:510-454-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG45972208D00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G459720Medicaid
CA00G459720Medicaid
00G459720Medicare ID - Type Unspecified