Provider Demographics
NPI:1699763607
Name:PETERSON, MARK DELANO (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:DELANO
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 E BARNETT RD
Mailing Address - Street 2:STE 201
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8225
Mailing Address - Country:US
Mailing Address - Phone:541-779-5007
Mailing Address - Fax:541-779-5022
Practice Address - Street 1:1311 E BARNETT RD
Practice Address - Street 2:STE 201
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8225
Practice Address - Country:US
Practice Address - Phone:541-779-5007
Practice Address - Fax:541-779-5022
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD18861207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR128129Medicaid
00WCGKNGMedicare ID - Type Unspecified
OR128129Medicaid