Provider Demographics
NPI:1528089224
Name:PETERSON, MARK (DPT)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9070 W CHEYENNE AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89129-8935
Mailing Address - Country:US
Mailing Address - Phone:702-818-5000
Mailing Address - Fax:
Practice Address - Street 1:360 S STATE ST STE C110
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-5729
Practice Address - Country:US
Practice Address - Phone:801-850-9146
Practice Address - Fax:801-373-7486
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT344238-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP37992Medicare UPIN
UT005586501Medicare ID - Type Unspecified