Provider Demographics
NPI:1194768606
Name:PETERSON, MICHAEL THEODORE (DO)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:THEODORE
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:601 PARK ST
Mailing Address - Street 2:
Mailing Address - City:HONESDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18431-1445
Mailing Address - Country:US
Mailing Address - Phone:570-226-2151
Mailing Address - Fax:570-226-1861
Practice Address - Street 1:132 MANLY RD
Practice Address - Street 2:
Practice Address - City:TAFTON
Practice Address - State:PA
Practice Address - Zip Code:18464-7829
Practice Address - Country:US
Practice Address - Phone:570-226-2151
Practice Address - Fax:570-226-1861
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS-007805L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPE744170OtherHIGHMARK BLUE SHIELD
PA003000OtherFIRST PRIORITY HEALTH
NY02042395OtherNY MEDICAL ASSISTANCE
PA0014151170001Medicaid
PA8873OtherGEISINGER HEALTH PLAN
NY02042395OtherNY MEDICAL ASSISTANCE
PA8873OtherGEISINGER HEALTH PLAN
PAPE744170OtherHIGHMARK BLUE SHIELD