Provider Demographics
NPI:1386036077
Name:CAMERON G PETERSON PC
Entity Type:Organization
Organization Name:CAMERON G PETERSON PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CAMERON
Authorized Official - Middle Name:G
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-598-8337
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 1:740 E 150 S
Practice Address - Street 2:
Practice Address - City:HYDE PARK
Practice Address - State:UT
Practice Address - Zip Code:84318-3541
Practice Address - Country:US
Practice Address - Phone:801-598-8337
Practice Address - Fax:801-294-6917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-04
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-12132208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty