Provider Demographics
NPI:1528020955
Name:PETERSON, MICHAEL S (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:PETERSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 W 12300 S
Mailing Address - Street 2:STE 111
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-9816
Mailing Address - Country:US
Mailing Address - Phone:801-679-9177
Mailing Address - Fax:801-878-7674
Practice Address - Street 1:1553 E 3080 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-3419
Practice Address - Country:US
Practice Address - Phone:801-879-8721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-03
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP100079152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807202700Medicaid
ID000010151065OtherREGENCE BLUE SHIELD OF ID
IDV6861OtherBLUE CROSS OF IDAHO
V05754Medicare UPIN
IDV6861OtherBLUE CROSS OF IDAHO