Provider Demographics
NPI:1497067136
Name:PETERSON, MARK R (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:R
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7321 BALMER ST BLDG 570
Mailing Address - Street 2:
Mailing Address - City:HILL AFB
Mailing Address - State:UT
Mailing Address - Zip Code:84056-5012
Mailing Address - Country:US
Mailing Address - Phone:801-777-5285
Mailing Address - Fax:
Practice Address - Street 1:7321 BALMER ST BLDG 570
Practice Address - Street 2:
Practice Address - City:HILL AFB
Practice Address - State:UT
Practice Address - Zip Code:84056-5012
Practice Address - Country:US
Practice Address - Phone:801-777-5285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-10
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102203109208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics