Provider Demographics
NPI:1700932639
Name:PETER V WILSON, MD, PLLC
Entity Type:Organization
Organization Name:PETER V WILSON, MD, PLLC
Other - Org Name:DAVIS SURGICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:V
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-728-9555
Mailing Address - Street 1:PO BOX 95970
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-0970
Mailing Address - Country:US
Mailing Address - Phone:801-352-9500
Mailing Address - Fax:801-352-9502
Practice Address - Street 1:1580 W ANTELOPE DR
Practice Address - Street 2:SUITE 130
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-1160
Practice Address - Country:US
Practice Address - Phone:801-728-9555
Practice Address - Fax:801-728-9556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000057051Medicare PIN