Healthcare Provider Details

I. General information

NPI: 1326374562
Provider Name (Legal Business Name): MARK WILLIAM PETERSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2009
Last Update Date: 02/18/2020
Certification Date: 02/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 PARK AVE. BLDG. D STE. 100
PARK CITY UT
84060
US

IV. Provider business mailing address

101 SUN MEADOW DR
CENTERTON AR
72719-9610
US

V. Phone/Fax

Practice location:
  • Phone: 435-615-8822
  • Fax: 435-615-8823
Mailing address:
  • Phone: 479-795-0426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number5101018542
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101018542
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE7679
License Number StateAR
# 4
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number8743560-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: