Healthcare Provider Details

I. General information

NPI: 1336407790
Provider Name (Legal Business Name): ANTHONY MICHAEL PETERSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2012
Last Update Date: 02/26/2026
Certification Date: 02/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6550 S MILLROCK DR STE 250
SALT LAKE CITY UT
84121-2331
US

IV. Provider business mailing address

6550 S MILLROCK DR STE 250
SALT LAKE CITY UT
84121-2331
US

V. Phone/Fax

Practice location:
  • Phone: 801-821-2781
  • Fax: 801-901-1194
Mailing address:
  • Phone: 801-821-2613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number8797789-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD457218
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: