Healthcare Provider Details

I. General information

NPI: 1093775025
Provider Name (Legal Business Name): MARK ALAN PETERSON PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 08/20/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 CEDAR RD
VISTA CA
92083-5102
US

IV. Provider business mailing address

10790 RANCHO BERNARDO RD # 4S-305
SAN DIEGO CA
92127-5705
US

V. Phone/Fax

Practice location:
  • Phone: 760-901-5040
  • Fax:
Mailing address:
  • Phone: 760-901-5040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number17962
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: