Provider Demographics
NPI:1487844791
Name:PETERS, NICOLAS LEE (MD)
Entity type:Individual
Prefix:DR
First Name:NICOLAS
Middle Name:LEE
Last Name:PETERS
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 1:70 S VAL VISTA DR STE A3-618
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-1374
Mailing Address - Country:US
Mailing Address - Phone:480-485-5166
Mailing Address - Fax:877-991-6652
Practice Address - Street 1:2204 S DOBSON RD STE 102
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-6457
Practice Address - Country:US
Practice Address - Phone:480-485-5166
Practice Address - Fax:877-991-6652
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2025-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ481902080P0207X, 208000000X, 208M00000X
OH35.094612208000000X, 2080P0207X
246QM0706X
NMMD2017-0087208M00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
No246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ845215Medicaid
NM98035339Medicaid
OH0070938Medicaid