Provider Demographics
NPI:1588635544
Name:PETERSON, MARK STEVEN (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:STEVEN
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 1:677 N WILMOT RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-2701
Mailing Address - Country:US
Mailing Address - Phone:520-795-2889
Mailing Address - Fax:520-795-6321
Practice Address - Street 1:677 N WILMOT RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-2701
Practice Address - Country:US
Practice Address - Phone:520-795-2889
Practice Address - Fax:520-795-6321
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ237132085R0202X, 2085B0100X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ005472OtherGROUP MEDICAID ID
AZ300129081OtherMEDICARE RAILROAD
AZ645369Medicaid
AZCS7943OtherGROUP MEDICARE RAILROAD ID & PTAN
AZZWCBBMOtherGROUP MEDICARE ID
AZ1588635544OtherPHYSICIAN INDIVIDUAL NPI
AZ1841261989OtherGROUP NPI
AZ645369Medicaid
AZZWCBBMOtherGROUP MEDICARE ID