Provider Demographics
NPI:1437177656
Name:PETERSON, MICHAEL SCOTT (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SCOTT
Last Name:PETERSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 BROAD ROCK BLVD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23249-0001
Mailing Address - Country:US
Mailing Address - Phone:804-675-5000
Mailing Address - Fax:804-675-5908
Practice Address - Street 1:1201 BROAD ROCK BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23249-0001
Practice Address - Country:US
Practice Address - Phone:804-675-5000
Practice Address - Fax:804-675-5908
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7533152WC0802X
MI4901004024152WS0006X
VA0618002288152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4309851Medicaid
MI4309851Medicaid
MI0Q27636005Medicare ID - Type Unspecified
MI0377500001Medicare NSC
TXTXB114012Medicare PIN
TXTXB122703Medicare PIN