Provider Demographics
NPI:1881798379
Name:PETERSEN, MICHAEL CHARLES (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:CHARLES
Last Name:PETERSEN
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 1:12356 RIATA TRACE PKWY # 6006-B
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78727-6417
Mailing Address - Country:US
Mailing Address - Phone:512-506-7000
Mailing Address - Fax:314-251-4450
Practice Address - Street 1:12356 RIATA TRACE PKWY # 6006-B
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78727-6417
Practice Address - Country:US
Practice Address - Phone:512-506-7000
Practice Address - Fax:314-251-4450
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006027561208000000X
TXQ20492080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201473808Medicaid
MO201473808Medicaid