Provider Demographics
NPI:1295112951
Name:PETERSEN, DAVID
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1648 N VENETIAN WAY
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:UT
Mailing Address - Zip Code:84045-3150
Mailing Address - Country:US
Mailing Address - Phone:801-440-5839
Mailing Address - Fax:
Practice Address - Street 1:1648 N VENETIAN WAY
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:UT
Practice Address - Zip Code:84045-3150
Practice Address - Country:US
Practice Address - Phone:801-440-5839
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-01
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program