Basic Information
Provider Information | |||||||||
NPI: | 1164539987 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PETERSON | ||||||||
FirstName: | WALLACE | ||||||||
MiddleName: | CURTIS | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1954 FORT UNION BLVD | ||||||||
Address2: | #111 | ||||||||
City: | SALT LAKE CITY | ||||||||
State: | UT | ||||||||
PostalCode: | 841216800 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8019939551 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 100 N MEDICAL DR | ||||||||
Address2: |   | ||||||||
City: | SALT LAKE CITY | ||||||||
State: | UT | ||||||||
PostalCode: | 841131103 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8019939551 | ||||||||
FaxNumber: | 8017335872 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/25/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 168281-1205 | UT | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | QM0000049533 | 01 | UT | ALTIUS | OTHER | 107006366101 | 01 | UT | IHC | OTHER | 2330 | 01 | UT | HEALTHY U | OTHER | 870280408PE2 | 01 | UT | EDUCATORS MUTUAL | OTHER | 24409 | 01 | UT | PEHP | OTHER | PR00612 | 01 | UT | MOLINA | OTHER | 401765 | 05 | MT |   | MEDICAID | 416944 | 01 | UT | DESERET MUTUAL | OTHER | 2000040 | 01 | UT | UNITED HEALTHCARE | OTHER | 710287 | 05 | AZ |   | MEDICAID |