Provider Demographics
NPI:1740226430
Name:PETERSON, MARK ALBRECHT (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALBRECHT
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 1:6204 MEADOW CT
Mailing Address - Street 2:
Mailing Address - City:NORTH BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20852-3637
Mailing Address - Country:US
Mailing Address - Phone:301-468-2668
Mailing Address - Fax:
Practice Address - Street 1:9601 BLACKWELL RD
Practice Address - Street 2:SUITE 100
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3472
Practice Address - Country:US
Practice Address - Phone:301-340-9200
Practice Address - Fax:301-340-6934
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0047108174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDE54868Medicare UPIN
MD002617S16Medicare PIN