Individual
MICHAEL C PETERSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1034 N 500 W, PROVO, UT 84604-3380
(801) 373-4366
(801) 429-8191
Mailing address
1055 N 500 W, CREDENTIALING DEPARTMENT, PROVO, UT 84604-3305
(801) 354-8225
(801) 418-0941
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
187826-1205
UT
207R00000X
Internal Medicine Physician
Primary
187826-1205
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
870419324004
—
UT
Enumeration date
07/21/2006
Last updated
11/27/2023
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