Healthcare Provider Details

I. General information

NPI: 1982844098
Provider Name (Legal Business Name): PETER GEORGE FORSTALL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2009
Last Update Date: 01/13/2022
Certification Date: 01/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 E 5350 S STE 400
OGDEN UT
84405-6932
US

IV. Provider business mailing address

PO BOX 741729
ATLANTA GA
30374-1729
US

V. Phone/Fax

Practice location:
  • Phone: 801-476-0184
  • Fax: 801-479-5642
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number5416513-1205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number5416513-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: