Provider Demographics
NPI:1851482202
Name:PETERSEN, DAVID B (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:B
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:4400 SOUTH 700 E
Mailing Address - Street 2:100
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107
Mailing Address - Country:US
Mailing Address - Phone:801-264-4450
Mailing Address - Fax:801-264-4409
Practice Address - Street 1:4400 SO 700 E
Practice Address - Street 2:100
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107
Practice Address - Country:US
Practice Address - Phone:801-264-4450
Practice Address - Fax:801-264-4409
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT52616771205207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870544230002Medicaid
H71143Medicare UPIN