Provider Demographics
NPI:1255543468
Name:PETERSON, MARY DAHLEN (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:DAHLEN
Last Name:PETERSON
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 1:210 NAPLES ST
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78404-1831
Mailing Address - Country:US
Mailing Address - Phone:361-694-4889
Mailing Address - Fax:
Practice Address - Street 1:3533 S ALAMEDA ST
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-1721
Practice Address - Country:US
Practice Address - Phone:361-694-4889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF9945207L00000X, 207LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Not Answered207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine