Provider Demographics
NPI:1477647246
Name:BOSSART, PETER WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:WILLIAM
Last Name:BOSSART
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 1:1250 E 3900 S STE 320
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1350
Mailing Address - Country:US
Mailing Address - Phone:801-263-1621
Mailing Address - Fax:801-906-0556
Practice Address - Street 1:1250 E 3900 S STE 320
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1350
Practice Address - Country:US
Practice Address - Phone:801-263-1621
Practice Address - Fax:801-906-0556
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT181676-1205208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTE27805Medicare UPIN