Healthcare Provider Details

I. General information

NPI: 1902899057
Provider Name (Legal Business Name): MICHAEL JAMES PETERSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 06/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 TECHNOLOGY DR SUITE 120
EAST SETAUKET NY
11733-4068
US

IV. Provider business mailing address

4 TECHNOLOGY DR SUITE 120
EAST SETAUKET NY
11733-4068
US

V. Phone/Fax

Practice location:
  • Phone: 631-246-8289
  • Fax: 631-246-8294
Mailing address:
  • Phone: 631-246-8289
  • Fax: 631-246-8294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number175936
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number175936
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: