Provider Demographics
NPI:1134182355
Name:PETERSON, MARK G (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:G
Last Name:PETERSON
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 5210
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58206-5210
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2650 32ND AVE S STE D
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-6541
Practice Address - Country:US
Practice Address - Phone:701-732-2700
Practice Address - Fax:701-732-2701
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND7376207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND18675Medicaid
MN453615100Medicaid
ND26183OtherBCBS OF ND
MN244P5PEOtherBCBS OF MN
NDE72266Medicare UPIN