Provider Demographics
NPI:1770044471
Name:PETERSON, MARTEN B (MD)
Entity Type:Individual
Prefix:
First Name:MARTEN
Middle Name:B
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 1:3 IRONGATE CTR STE 2
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-3473
Mailing Address - Country:US
Mailing Address - Phone:518-793-4409
Mailing Address - Fax:
Practice Address - Street 1:3 IRONGATE CENTER
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-3473
Practice Address - Country:US
Practice Address - Phone:518-793-4409
Practice Address - Fax:518-615-0148
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY308195208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice