Provider Demographics
NPI:1518918713
Name:PETERSON, MARCUS L (MD)
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:L
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 1:676 S BLUFF ST
Mailing Address - Street 2:#207
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-3568
Mailing Address - Country:US
Mailing Address - Phone:435-628-2895
Mailing Address - Fax:435-628-5943
Practice Address - Street 1:676 S BLUFF ST
Practice Address - Street 2:#207
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-3568
Practice Address - Country:US
Practice Address - Phone:435-628-2895
Practice Address - Fax:435-628-5943
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT183446-1205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT201302847OtherOTHER ID
UT19344612000001OtherREGENCE
UT107029664101OtherIHC
UT201302841793981OtherUS HEALTH
NV2085401OtherBCBS NV
UT902568OtherDMBA
UT201302841OtherCURRENT TAX ID
UT870436699OtherOLD TAX ID
UT107007770102OtherIHC
UT902568OtherDMBA
UT870436699OtherOLD TAX ID
UT201302841793981OtherUS HEALTH
NV2085401OtherBCBS NV