Provider Demographics
NPI:1750319943
Name:PETERSON, DAVID CHRISTOPHER (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:CHRISTOPHER
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 1:630 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-4908
Mailing Address - Country:US
Mailing Address - Phone:801-299-2160
Mailing Address - Fax:801-299-2549
Practice Address - Street 1:630 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4908
Practice Address - Country:US
Practice Address - Phone:801-299-2160
Practice Address - Fax:801-299-2549
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY235854207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTI55217Medicaid
UTD6794Medicaid