Healthcare Provider Details

I. General information

NPI: 1356312524
Provider Name (Legal Business Name): MARK W PETERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 6TH ST
LEWISTON ID
83501-2431
US

IV. Provider business mailing address

531 4TH AVE
LEWISTON ID
83501-2450
US

V. Phone/Fax

Practice location:
  • Phone: 208-799-5335
  • Fax:
Mailing address:
  • Phone: 208-743-4393
  • Fax: 208-743-4214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberM5240
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberM5240
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: