Individual
DR. MARK IRWIN PETERSEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
21107 DONAHOO RD, TONGANOXIE, KS 66086-4153
(913) 742-4084
(913) 742-4086
Mailing address
PO BOX 996, TONGANOXIE, KS 66086-0996
(913) 742-4084
(913) 742-4086
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
04-21601
KS
207R00000X
Internal Medicine Physician
Primary
0421601
KS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100135660B
—
KS
01
—
13217089
BCBS
—
01
—
2050317102
RAILROAD MEDICARE
—
Enumeration date
05/17/2006
Last updated
10/08/2024
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