=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922522762
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARLA PETERS MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2017
-----------------------------------------------------
Last Update Date | 06/16/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1075 SW GRANDVIEW AVE STE 200
-----------------------------------------------------
City | GRANTS PASS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97527-5118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-479-8363
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1075 SW GRANDVIEW AVE STE 200
-----------------------------------------------------
City | GRANTS PASS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97527-5118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-479-8363
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | MD210647
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------