Provider Demographics
NPI:1831130863
Name:PETERSON, MARK ARTHUR (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ARTHUR
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:438 RIVIERA CIR
Mailing Address - Street 2:
Mailing Address - City:LARKSPUR
Mailing Address - State:CA
Mailing Address - Zip Code:94939-1510
Mailing Address - Country:US
Mailing Address - Phone:415-461-7955
Mailing Address - Fax:415-927-8858
Practice Address - Street 1:1300 S ELISEO DR
Practice Address - Street 2:STE 104
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-2023
Practice Address - Country:US
Practice Address - Phone:415-461-7955
Practice Address - Fax:415-927-8858
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC40987208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C409870Medicaid
CA020006844OtherRAILROAD MEDICARE
CA020006844OtherRAILROAD MEDICARE
CA00C409870Medicare ID - Type Unspecified
A37496Medicare UPIN