Provider Demographics
NPI:1558481366
Name:PETERSON, MARK THEODORE (NAPRAPATH)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:THEODORE
Last Name:PETERSON
Suffix:
Gender:M
Credentials:NAPRAPATH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5712 NEWBURG RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-6707
Mailing Address - Country:US
Mailing Address - Phone:815-397-8840
Mailing Address - Fax:
Practice Address - Street 1:5712 NEWBURG RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-6707
Practice Address - Country:US
Practice Address - Phone:815-397-8840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist