Individual
MICHAEL S PETERSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
O.D.
Contact information
Practice address
1553 E 3080 S, SALT LAKE CITY, UT 84106-3419
(801) 879-8721
Mailing address
177 W 12300 S, STE 111, DRAPER, UT 84020-9816
(801) 679-9177
(801) 878-7674
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
ODP100079
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010151065
REGENCE BLUE SHIELD OF ID
ID
05
—
807202700
—
ID
01
—
V6861
BLUE CROSS OF IDAHO
ID
Enumeration date
04/03/2006
Last updated
07/07/2014
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