Provider Demographics
NPI:1194775429
Name:PETERS, MICHAEL D (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
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 1:1859 HICKORY LN
Mailing Address - Street 2:
Mailing Address - City:LONGS
Mailing Address - State:SC
Mailing Address - Zip Code:29568-6519
Mailing Address - Country:US
Mailing Address - Phone:843-222-1142
Mailing Address - Fax:
Practice Address - Street 1:3806 SAWTELL RD
Practice Address - Street 2:
Practice Address - City:LITTLE RIVER
Practice Address - State:SC
Practice Address - Zip Code:29566-7873
Practice Address - Country:US
Practice Address - Phone:843-663-9090
Practice Address - Fax:843-663-9091
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2024-07-30
Deactivation Date:2024-06-17
Deactivation Code:
Reactivation Date:2024-07-19
Provider Licenses
StateLicense IDTaxonomies
NC2013-01576207YS0123X
SCMD28577207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
No207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
H49124Medicare UPIN