Healthcare Provider Details

I. General information

NPI: 1699882514
Provider Name (Legal Business Name): MICHAEL L PETERSON D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 11/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6808 S MEMORIAL DR STE 100
TULSA OK
74133-2066
US

IV. Provider business mailing address

6808 S MEMORIAL DR STE 100
TULSA OK
74133-2066
US

V. Phone/Fax

Practice location:
  • Phone: 918-481-0655
  • Fax: 918-481-8729
Mailing address:
  • Phone: 918-481-0655
  • Fax: 918-481-8729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number3020
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: