Basic Information
| Provider Information | |||||||||
| NPI: | 1770044471 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | MARTEN | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 IRONGATE CTR STE 2 | ||||||||
| Address2: | |||||||||
| City: | GLENS FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128013473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187934409 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3 IRONGATE CENTER | ||||||||
| Address2: | |||||||||
| City: | GLENS FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128013473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187934409 | ||||||||
| FaxNumber: | 5186150148 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2019 | ||||||||
| LastUpdateDate: | 09/22/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 308195 | NY | N | Allopathic & Osteopathic Physicians | General Practice | 207Q00000X | 308195 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.