Provider Demographics
NPI:1689943300
Name:ASPEN DERMATOPATHOLOGY
Entity Type:Organization
Organization Name:ASPEN DERMATOPATHOLOGY
Other - Org Name:DBA ALPINE DERMATOPATHOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:801-210-8989
Mailing Address - Street 1:114 E 800 N
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-1209
Mailing Address - Country:US
Mailing Address - Phone:801-794-1490
Mailing Address - Fax:801-794-0316
Practice Address - Street 1:732 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGVILLE
Practice Address - State:UT
Practice Address - Zip Code:84663-1034
Practice Address - Country:US
Practice Address - Phone:801-210-8989
Practice Address - Fax:801-723-0126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-27
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1770634909291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory