Provider Demographics
NPI:1437620796
Name:PETERS, MARK JOSEPH (RCP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JOSEPH
Last Name:PETERS
Suffix:
Gender:M
Credentials:RCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1617 E ORANGEBURG AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-3236
Mailing Address - Country:US
Mailing Address - Phone:209-613-6591
Mailing Address - Fax:
Practice Address - Street 1:1777 W YOSEMITE AVE
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95337-5187
Practice Address - Country:US
Practice Address - Phone:209-825-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21073227800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Certified