Healthcare Provider Details

I. General information

NPI: 1326148800
Provider Name (Legal Business Name): MARK DAVID PETERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2006
Last Update Date: 09/18/2023
Certification Date: 09/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2632 N 20TH ST
PHOENIX AZ
85006-1339
US

IV. Provider business mailing address

PO BOX 61773
PHOENIX AZ
85082-1773
US

V. Phone/Fax

Practice location:
  • Phone: 602-266-2200
  • Fax: 602-240-6177
Mailing address:
  • Phone: 602-682-6701
  • Fax: 602-240-6177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number35706
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number35706
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number321958
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: