Provider Demographics
NPI:1750351441
Name:PETERSON, SCOTT DAVID (OD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:DAVID
Last Name:PETERSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3988 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-1826
Mailing Address - Country:US
Mailing Address - Phone:801-621-2883
Mailing Address - Fax:801-334-7930
Practice Address - Street 1:3988 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-1826
Practice Address - Country:US
Practice Address - Phone:801-621-2883
Practice Address - Fax:801-334-7930
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT111436-9934152W00000X, 152WC0802X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000061867Medicare PIN
UT410002727Medicare PIN
UTT78138Medicare UPIN
UT0543760001Medicare PIN
UT000009464Medicare PIN