Provider Demographics
NPI:1164539987
Name:PETERSON, WALLACE CURTIS (MD)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:CURTIS
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 1:1954 FORT UNION BLVD
Mailing Address - Street 2:#111
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-6800
Mailing Address - Country:US
Mailing Address - Phone:801-993-9551
Mailing Address - Fax:
Practice Address - Street 1:100 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1103
Practice Address - Country:US
Practice Address - Phone:801-993-9551
Practice Address - Fax:801-733-5872
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT168281-1205207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTQM0000049533OtherALTIUS
UT107006366101OtherIHC
UT2330OtherHEALTHY U
UT870280408PE2OtherEDUCATORS MUTUAL
UT24409OtherPEHP
UTPR00612OtherMOLINA
MT401765Medicaid
UT416944OtherDESERET MUTUAL
UT2000040OtherUNITED HEALTHCARE
AZ710287Medicaid
UT2000040OtherUNITED HEALTHCARE
AZ710287Medicaid