Provider Demographics
NPI:1326148800
Name:PETERSON, MARK DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DAVID
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:PO BOX 61773
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85082-1773
Mailing Address - Country:US
Mailing Address - Phone:602-682-6701
Mailing Address - Fax:602-240-6177
Practice Address - Street 1:2632 N 20TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-1339
Practice Address - Country:US
Practice Address - Phone:602-266-2200
Practice Address - Fax:602-240-6177
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ35706208600000X, 2086S0129X
NY321958208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ147570Medicaid
AZWCSKQOtherSUN HEALTH GROUP #
AZ35706OtherAZ LICENSE #
AZCPSO 72684OtherONTARIO MEDICAL LICENSE
AZWCSKQOtherSUN HEALTH GROUP #
AZ35706OtherAZ LICENSE #