Provider Demographics
NPI:1992884894
Name:MICHAEL L PEASTER M D P C
Entity type:Organization
Organization Name:MICHAEL L PEASTER M D P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:PEASTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-338-3800
Mailing Address - Street 1:500 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74003-3909
Mailing Address - Country:US
Mailing Address - Phone:918-338-3800
Mailing Address - Fax:918-336-1505
Practice Address - Street 1:500 E 5TH ST
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74003-3909
Practice Address - Country:US
Practice Address - Phone:918-338-3800
Practice Address - Fax:918-336-1505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23383208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F11831Medicare UPIN