Provider Demographics
NPI:1952311797
Name:FENTON, PETER C O (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:C O
Last Name:FENTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6360 S 3000 E
Mailing Address - Street 2:#220
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-6926
Mailing Address - Country:US
Mailing Address - Phone:801-944-3189
Mailing Address - Fax:801-944-3180
Practice Address - Street 1:6360 S 3000 E
Practice Address - Street 2:SUITE 310
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-6926
Practice Address - Country:US
Practice Address - Phone:801-944-3144
Practice Address - Fax:801-944-3186
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4822480-1205207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000059320Medicare PIN
UTH54220Medicare UPIN