Provider Demographics
NPI:1487727897
Name:PETERSEN, MARK THOMAS (DC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:THOMAS
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 ROCHESTER HILL RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03867-3212
Mailing Address - Country:US
Mailing Address - Phone:603-335-2566
Mailing Address - Fax:603-335-2566
Practice Address - Street 1:7 ROCHESTER HILL RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03867-3212
Practice Address - Country:US
Practice Address - Phone:603-335-2566
Practice Address - Fax:603-335-2566
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH14302560584A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30250639Medicaid
NHT25758Medicare UPIN
NHNH8448Medicare ID - Type Unspecified