Provider Demographics
NPI:1124011572
Name:PETERSEN, ANDREW D (DO)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:D
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:524 W 300 N STE 203
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-2669
Mailing Address - Country:US
Mailing Address - Phone:801-607-5268
Mailing Address - Fax:801-607-5271
Practice Address - Street 1:524 W 300 N STE 203
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-2669
Practice Address - Country:US
Practice Address - Phone:801-607-5268
Practice Address - Fax:801-607-5271
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM4441207Q00000X
UT8382699-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX184033201Medicaid
KS207Q00000XOtherTAXONOMY
TX184033201Medicaid
KSI15842Medicare UPIN