Provider Demographics
NPI:1326374562
Name:PETERSON, MARK WILLIAM (DO)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:WILLIAM
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:101 SUN MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:CENTERTON
Mailing Address - State:AR
Mailing Address - Zip Code:72719-9610
Mailing Address - Country:US
Mailing Address - Phone:479-795-0426
Mailing Address - Fax:
Practice Address - Street 1:2200 PARK AVE. BLDG. D STE. 100
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060
Practice Address - Country:US
Practice Address - Phone:435-615-8822
Practice Address - Fax:435-615-8823
Is Sole Proprietor?:No
Enumeration Date:2009-10-22
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101018542207Q00000X, 390200000X
ARE7679207Q00000X
UT8743560-1204207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program