Healthcare Provider Details

I. General information

NPI: 1346245586
Provider Name (Legal Business Name): MARK ANTHONY PETERS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 NW LOVEJOY ST STE 100
PORTLAND OR
97210-2861
US

IV. Provider business mailing address

2525 NW LOVEJOY ST STE 100
PORTLAND OR
97210-2861
US

V. Phone/Fax

Practice location:
  • Phone: 503-274-2121
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD14091
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD00024996
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: