Provider Demographics
NPI:1770634909
Name:PETERSON, MICHAEL WARREN (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WARREN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:732 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84663-1034
Mailing Address - Country:US
Mailing Address - Phone:801-704-7001
Mailing Address - Fax:801-210-7012
Practice Address - Street 1:114 EAST 800 NORTH
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660
Practice Address - Country:US
Practice Address - Phone:801-794-1490
Practice Address - Fax:801-794-1495
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7247463-1204207N00000X
WI47784-021207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000060388Medicare PIN
UT09858Medicare PIN