Provider Demographics
NPI:1881647543
Name:PETERSEN, MARK IRWIN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:IRWIN
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 996
Mailing Address - Street 2:
Mailing Address - City:TONGANOXIE
Mailing Address - State:KS
Mailing Address - Zip Code:66086-0996
Mailing Address - Country:US
Mailing Address - Phone:913-742-4084
Mailing Address - Fax:913-742-4086
Practice Address - Street 1:21107 DONAHOO RD
Practice Address - Street 2:
Practice Address - City:TONGANOXIE
Practice Address - State:KS
Practice Address - Zip Code:66086-4153
Practice Address - Country:US
Practice Address - Phone:913-742-4084
Practice Address - Fax:913-742-4086
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2010-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0421601207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100135660BMedicaid
2050317102OtherRAILROAD MEDICARE
13217089OtherBCBS
13217089OtherBCBS
2050317102OtherRAILROAD MEDICARE