Provider Demographics
NPI:1548251408
Name:PEITSO, MARILYN J (MD)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:J
Last Name:PEITSO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 CENTRACARE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303
Mailing Address - Country:US
Mailing Address - Phone:320-654-3630
Mailing Address - Fax:320-654-3657
Practice Address - Street 1:1900 CENTRACARE CIRCLE
Practice Address - Street 2:
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303
Practice Address - Country:US
Practice Address - Phone:320-654-3630
Practice Address - Fax:320-654-3657
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26871208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
1202204OtherMEDICA HEALTH PLANS
2114138OtherFIRST HEALTH PLAN
037707400OtherMEDICAL ASSISTANCE MA
110144OtherUCARE
254020OtherPREFERRED ONE
596183OtherARAZ GROUP AMERICAS PPO
51A38PEOtherBLUE CROSS BLUE SHIELD
HP25503OtherHEALTH PARTNERS
HP25503OtherHEALTH PARTNERS
110144OtherUCARE
1202204OtherMEDICA HEALTH PLANS