Provider Demographics
NPI:1902899057
Name:PETERSEN, MICHAEL JAMES (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
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 1:4 TECHNOLOGY DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-4068
Mailing Address - Country:US
Mailing Address - Phone:631-246-8289
Mailing Address - Fax:631-246-8294
Practice Address - Street 1:4 TECHNOLOGY DR
Practice Address - Street 2:SUITE 120
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-4068
Practice Address - Country:US
Practice Address - Phone:631-246-8289
Practice Address - Fax:631-246-8294
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY175936174400000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2C4298OtherHEALTHNET
NY0714028004OtherCIGNA HEALTHCARE
NY990015026OtherRR MEDICARE
NYS500051OtherSUFFOLK HEALTH PLANS
NY11347567803Other1199 BENEFIT FUND
NM2110430OtherAETNA HEALTH PLANS
NYCS1072OtherOXFORD HEALTH PLANS
NY1261940OtherUNITED HEALTHCARE
NMGHI PPO CBPOther0103702
NY1261940OtherUNITED HEALTHCARE
NM2110430OtherAETNA HEALTH PLANS