Healthcare Provider Details

I. General information

NPI: 1962532465
Provider Name (Legal Business Name): DAVID O. PETERSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 10/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1840 WEALTHY ST SE
GRAND RAPIDS MI
49506-2921
US

IV. Provider business mailing address

36123 SCHOOLCRAFT RD
LIVONIA MI
48150-1216
US

V. Phone/Fax

Practice location:
  • Phone: 734-464-0887
  • Fax: 734-402-0254
Mailing address:
  • Phone: 734-793-6140
  • Fax: 734-402-0254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number006401
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number5101006401
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: