Provider Demographics
NPI:1831338029
Name:WARREN A PETERSON, D.O.
Entity type:Organization
Organization Name:WARREN A PETERSON, D.O.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:A
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-224-5200
Mailing Address - Street 1:1385 E 750 N
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84097-5480
Mailing Address - Country:US
Mailing Address - Phone:801-224-5200
Mailing Address - Fax:801-224-2667
Practice Address - Street 1:1385 E 750 N
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84097-5480
Practice Address - Country:US
Practice Address - Phone:801-224-5200
Practice Address - Fax:801-224-2667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-11
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1790771204207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000011445Medicare PIN