Provider Demographics
NPI:1518998921
Name:WILSON, PETER V (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:V
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 95970
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-0970
Mailing Address - Country:US
Mailing Address - Phone:801-352-9500
Mailing Address - Fax:801-352-9502
Practice Address - Street 1:1580 W ANTELOPE DR
Practice Address - Street 2:SUITE #230
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-1160
Practice Address - Country:US
Practice Address - Phone:801-728-9555
Practice Address - Fax:801-728-9556
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT5619005-1205208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTI13883Medicare UPIN
UT005705101Medicare PIN