Provider Demographics
NPI:1134198807
Name:PETERSON, WARREN ALBERT (DO)
Entity type:Individual
Prefix:DR
First Name:WARREN
Middle Name:ALBERT
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 1:78 E 900 N
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-1232
Mailing Address - Country:US
Mailing Address - Phone:801-794-1490
Mailing Address - Fax:801-794-1495
Practice Address - Street 1:78 EAST 900 NORTH
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-1232
Practice Address - Country:US
Practice Address - Phone:801-794-1490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-16
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT179077-1204207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005755801Medicare PIN