Provider Demographics
NPI:1104963156
Name:PETERS, DAVID M (DO)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:M
Last Name:PETERS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6910 S CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911-6912
Mailing Address - Country:US
Mailing Address - Phone:517-694-4134
Mailing Address - Fax:517-694-1629
Practice Address - Street 1:6910 S CEDAR ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-6912
Practice Address - Country:US
Practice Address - Phone:517-694-4134
Practice Address - Fax:517-694-1629
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDP008207207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1001919OtherMCLAREN
MIDP008207OtherLICENSE NUMBER
MI700C361780OtherBCBS
MI1001919OtherMCLAREN
MIE25737Medicare UPIN
MIDP008207OtherLICENSE NUMBER