Provider Demographics
NPI:1124110127
Name:PETERSON, MICHAEL W (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:W
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 1:735 N 5TH ST STE U
Mailing Address - Street 2:
Mailing Address - City:SILSBEE
Mailing Address - State:TX
Mailing Address - Zip Code:77656-3838
Mailing Address - Country:US
Mailing Address - Phone:409-291-0004
Mailing Address - Fax:
Practice Address - Street 1:600 S AUSTIN RD
Practice Address - Street 2:
Practice Address - City:EAGLE LAKE
Practice Address - State:TX
Practice Address - Zip Code:77434-3202
Practice Address - Country:US
Practice Address - Phone:979-234-5571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0994207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX029922416Medicaid
TX260202YKN5Medicare PIN