Healthcare Provider Details

I. General information

NPI: 1316978687
Provider Name (Legal Business Name): BRIAN R PETERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 11/02/2020
Certification Date: 11/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3584 W 9000 S SUITE 311
WEST JORDAN UT
84088-5710
US

IV. Provider business mailing address

3584 W 9000 S SUITE 311
WEST JORDAN UT
84088-5710
US

V. Phone/Fax

Practice location:
  • Phone: 801-566-8304
  • Fax: 801-566-8304
Mailing address:
  • Phone: 801-566-8304
  • Fax: 801-566-8304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number036142390
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License Number313974-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: