Provider Demographics
NPI:1003980053
Name:PETERSON, MARK STEVEN (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:STEVEN
Last Name:PETERSON
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 1:925 COMMERCIAL ST SE STE 102
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4173
Mailing Address - Country:US
Mailing Address - Phone:503-561-7227
Mailing Address - Fax:503-371-8334
Practice Address - Street 1:925 COMMERCIAL ST SE STE 102
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4173
Practice Address - Country:US
Practice Address - Phone:503-561-7227
Practice Address - Fax:503-671-8334
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD161352086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR010509Medicaid
OR010509Medicaid
ORE57532Medicare UPIN