Provider Demographics
NPI:1114376431
Name:PETERSON, JONAS LEGRAND (MD)
Entity Type:Individual
Prefix:
First Name:JONAS
Middle Name:LEGRAND
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4403 HARRISON BLVD
Mailing Address - Street 2:SUITE A-700
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-3271
Mailing Address - Country:US
Mailing Address - Phone:801-387-5300
Mailing Address - Fax:801-387-5333
Practice Address - Street 1:4403 HARRISON BLVD
Practice Address - Street 2:SUITE A-700
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3271
Practice Address - Country:US
Practice Address - Phone:801-387-5300
Practice Address - Fax:801-387-5333
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT104427351205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program