Provider Demographics
NPI:1356508675
Name:PETERSON, MARY KATHRYN (DO)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHRYN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:KATHRYN
Other - Last Name:DORAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:205 S NORTHWEST HWY STE 130
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-5802
Mailing Address - Country:US
Mailing Address - Phone:847-292-5200
Mailing Address - Fax:
Practice Address - Street 1:205 S NORTHWEST HWY STE 130
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-5802
Practice Address - Country:US
Practice Address - Phone:847-292-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-22
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036121820207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036121820Medicaid
IL036121820Medicaid
IL389780OtherMEDICARE GROUP-MEDICAL SURGICAL