Provider Demographics
NPI:1164532073
Name:PETERSON, DENNIS R (MDPC)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:R
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MDPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 307
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84011-0307
Mailing Address - Country:US
Mailing Address - Phone:801-294-6907
Mailing Address - Fax:801-294-6917
Practice Address - Street 1:415 MEDICAL DR
Practice Address - Street 2:SUITE B200
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4946
Practice Address - Country:US
Practice Address - Phone:801-292-7254
Practice Address - Fax:801-295-5494
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT158238-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD07309Medicare UPIN
UT000000923Medicare PIN