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
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101018542 | MI | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | E7679 | AR | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 390200000X | 5101018542 | MI | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207QS0010X | 8743560-1204 | UT | Y |   | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
No ID Information.