Provider Demographics
NPI:1548216765
Name:PETERSEN, RODNEY C (MD)
Entity Type:Individual
Prefix:
First Name:RODNEY
Middle Name:C
Last Name:PETERSEN
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 1:283 E 930 S
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84058-5001
Mailing Address - Country:US
Mailing Address - Phone:801-225-6246
Mailing Address - Fax:801-225-1525
Practice Address - Street 1:1034 N 500 W
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3380
Practice Address - Country:US
Practice Address - Phone:801-373-7850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT158619-12052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT228465OtherDMBA
UT870284448PE1OtherEMIA
UT107006210103OtherIHC
UT870284448PE1OtherEMIA