Provider Demographics
NPI:1497794960
Name:PETERSON, MICHAEL JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JAMES
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 1:5746 W 13400 S
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-6907
Mailing Address - Country:US
Mailing Address - Phone:801-253-4001
Mailing Address - Fax:801-253-4003
Practice Address - Street 1:5746 W 13400 S
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-6907
Practice Address - Country:US
Practice Address - Phone:801-253-4001
Practice Address - Fax:801-253-4003
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5354110-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005733901Medicare ID - Type Unspecified
UTH49473Medicare UPIN