Provider Demographics
NPI:1821299751
Name:PETERSON, CHAD (DO)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:
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 1:114 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:
Practice Address - Street 1:114 E 800 N
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-1209
Practice Address - Country:US
Practice Address - Phone:801-794-1490
Practice Address - Fax:801-794-1495
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4153207N00000X
UT5457858-1204207N00000X
UT54578581204207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology