Basic Information
| Provider Information | |||||||||
| NPI: | 1578651923 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | THEODORE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 366 | ||||||||
| Address2: | |||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973390366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417585047 | ||||||||
| FaxNumber: | 5417583713 | ||||||||
| Practice Location | |||||||||
| Address1: | 930 SW ABBEY ST | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973654820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417544710 | ||||||||
| FaxNumber: | 5415742858 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 05/07/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD09375 | OR | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 279000 | 05 | OR | MEDICAID |