Provider Demographics
NPI:1063856920
Name:RIRIE, PETER ALEXANDER
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:ALEXANDER
Last Name:RIRIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1735 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-1010
Mailing Address - Country:US
Mailing Address - Phone:801-374-1818
Mailing Address - Fax:801-379-2959
Practice Address - Street 1:12 N 1100 E
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-2952
Practice Address - Country:US
Practice Address - Phone:801-756-9627
Practice Address - Fax:801-763-0216
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT10288924-1205207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program