Provider Demographics
NPI:1942437058
Name:MICHAEL S PETERSON, OD, PC
Entity Type:Organization
Organization Name:MICHAEL S PETERSON, OD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:SHAWN
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:801-879-8721
Mailing Address - Street 1:1553 GREGSON AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-3419
Mailing Address - Country:US
Mailing Address - Phone:801-879-8721
Mailing Address - Fax:
Practice Address - Street 1:1553 GREGSON AVE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-3419
Practice Address - Country:US
Practice Address - Phone:801-879-8721
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT283356-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty