Healthcare Provider Details

I. General information

NPI: 1417299074
Provider Name (Legal Business Name): GARY L PETERSON DVM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2013
Last Update Date: 03/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 S STATE ST
SALT LAKE CITY UT
84111-4535
US

IV. Provider business mailing address

1220 S STATE ST
SALT LAKE CITY UT
84111-4535
US

V. Phone/Fax

Practice location:
  • Phone: 801-328-8543
  • Fax: 801-364-1803
Mailing address:
  • Phone: 801-328-8543
  • Fax: 801-364-1803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174M00000X
TaxonomyVeterinarian
License Number109676-2801
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: