Provider Demographics
NPI:1629489596
Name:PETERSON, MITCHELL ALAN (MD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:ALAN
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 1:1268 W SOUTH JORDAN PKWY STE 201
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-4653
Mailing Address - Country:US
Mailing Address - Phone:801-254-9700
Mailing Address - Fax:
Practice Address - Street 1:1268 W SOUTH JORDAN PKWY STE 201
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-4653
Practice Address - Country:US
Practice Address - Phone:801-254-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT9529304-1205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program