Healthcare Provider Details

I. General information

NPI: 1770634909
Provider Name (Legal Business Name): MICHAEL WARREN PETERSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2007
Last Update Date: 04/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 EAST 800 NORTH
SPANISH FORK UT
84660
US

IV. Provider business mailing address

732 N MAIN ST
SPRINGVILLE UT
84663-1034
US

V. Phone/Fax

Practice location:
  • Phone: 801-794-1490
  • Fax: 801-794-1495
Mailing address:
  • Phone: 801-704-7001
  • Fax: 801-210-7012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number7247463-1204
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number47784-021
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: