Basic Information
Provider Information
NPI: 1326374562
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PETERSON
FirstName: MARK
MiddleName: WILLIAM
NamePrefix: DR.
NameSuffix:  
Credential: DO
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 101 SUN MEADOW DR
Address2:  
City: CENTERTON
State: AR
PostalCode: 727199610
CountryCode: US
TelephoneNumber: 4797950426
FaxNumber:  
Practice Location
Address1: 2200 PARK AVE. BLDG. D STE. 100
Address2:  
City: PARK CITY
State: UT
PostalCode: 84060
CountryCode: US
TelephoneNumber: 4356158822
FaxNumber: 4356158823
Other Information
ProviderEnumerationDate: 10/22/2009
LastUpdateDate: 02/18/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 02/18/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000X5101018542MIN Allopathic & Osteopathic PhysiciansFamily Medicine 
207Q00000XE7679ARN Allopathic & Osteopathic PhysiciansFamily Medicine 
390200000X5101018542MIN Student, Health CareStudent in an Organized Health Care Education/Training Program 
207QS0010X8743560-1204UTY Allopathic & Osteopathic PhysiciansFamily MedicineSports Medicine

No ID Information.


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