Provider Demographics
NPI:1760490239
Name:PETERSEN, MARIO CESAR (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:CESAR
Last Name:PETERSEN
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 1:901 E 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97403-1354
Mailing Address - Country:US
Mailing Address - Phone:541-346-3575
Mailing Address - Fax:541-346-5844
Practice Address - Street 1:901 E 18TH AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97403-1354
Practice Address - Country:US
Practice Address - Phone:541-346-3575
Practice Address - Fax:541-346-5844
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD26196208000000X, 2080P0008X, 2080P0006X
MI43011167232080P0006X, 2080P0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR012290Medicaid
G40284Medicare UPIN