Provider Demographics
NPI:1851480081
Name:PETERSON, WALTER (OD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 PARKWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-2001
Mailing Address - Country:US
Mailing Address - Phone:801-886-2020
Mailing Address - Fax:801-954-0054
Practice Address - Street 1:250 RED CLIFFS DR
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-8167
Practice Address - Country:US
Practice Address - Phone:435-674-2020
Practice Address - Fax:435-674-3470
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1093699934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT999000797009Medicaid
UT87017934025001OtherBLUE CROSS/BLUE SHIELD
UT999000797009Medicaid
UT009922017Medicare ID - Type Unspecified
UT87017934025001OtherBLUE CROSS/BLUE SHIELD
UTU16556Medicare UPIN
UT0618950014Medicare NSC
UT000062793Medicare PIN