Provider Demographics
NPI:1750467668
Name:PETERS, MARILYNN JOANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARILYNN
Middle Name:JOANNE
Last Name:PETERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARILYNN
Other - Middle Name:PETERS
Other - Last Name:JOHNSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:871 MOSAIC CT
Mailing Address - Street 2:
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-3835
Mailing Address - Country:US
Mailing Address - Phone:614-939-9051
Mailing Address - Fax:614-939-9051
Practice Address - Street 1:700 BROOKSEDGE BLVD
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-2820
Practice Address - Country:US
Practice Address - Phone:614-882-9338
Practice Address - Fax:614-882-3401
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-0655862084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0866193Medicare ID - Type Unspecified