Provider Demographics
NPI:1538173190
Name:PETERSON-JONES, MICHELLE L (MD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:L
Last Name:PETERSON-JONES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11111 S 84TH ST
Mailing Address - Street 2:SUITE 2476
Mailing Address - City:PAPILLION
Mailing Address - State:NE
Mailing Address - Zip Code:68046-4122
Mailing Address - Country:US
Mailing Address - Phone:402-339-8991
Mailing Address - Fax:402-339-6741
Practice Address - Street 1:11111 S 84TH ST
Practice Address - Street 2:SUITE 2476
Practice Address - City:PAPILLION
Practice Address - State:NE
Practice Address - Zip Code:68046-4122
Practice Address - Country:US
Practice Address - Phone:402-339-8991
Practice Address - Fax:402-339-6741
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE214452085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IACJ3861Medicare PIN
IAP00307691Medicare PIN
NEP00246431Medicare PIN
IAI15407Medicare PIN
H54489Medicare UPIN
NEC50206Medicare PIN
NE279100Medicare PIN