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General NPI Number Information
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NPI Number | 1881647543
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Entity Type | Individual
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Provider Name | MARK IRWIN PETERSEN MD
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Gender | Male
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Dates
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Enumeration Date | 05/17/2006
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Last Update Date | 10/08/2024
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Provider Practice Location Address
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Address Line | 21107 DONAHOO RD
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City | TONGANOXIE
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State | KS
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Zip | 66086-4153
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Country | US
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Telephone | 913-742-4084
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Fax | 913-742-4086
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Provider Business Mailing Address
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Address Line | PO BOX 996
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City | TONGANOXIE
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State | KS
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Zip | 66086-0996
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Country | US
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Telephone | 913-742-4084
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Fax | 913-742-4086
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 04-21601
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License Number State | KS
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 0421601
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License Number State | KS
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