Provider Demographics
NPI:1609026897
Name:PETERSON, CHARLES MARQUIS (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:MARQUIS
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 1:1054 PATCHELL STREET
Mailing Address - Street 2:ATTN: MCMR-TT
Mailing Address - City:FORT DETRICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-5012
Mailing Address - Country:US
Mailing Address - Phone:301-619-4197
Mailing Address - Fax:301-619-2518
Practice Address - Street 1:12910 DALYN DR
Practice Address - Street 2:
Practice Address - City:POTOMAC
Practice Address - State:MD
Practice Address - Zip Code:20854-1176
Practice Address - Country:US
Practice Address - Phone:301-987-0847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-24
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG 026308207R00000X
WAL3589207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine