Basic Information
| Provider Information | |||||||||
| NPI: | 1851480081 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | WALTER | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1901 PARKWAY BLVD | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841192001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8018862020 | ||||||||
| FaxNumber: | 8019540054 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 RED CLIFFS DR | ||||||||
| Address2: | |||||||||
| City: | ST GEORGE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847908167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356742020 | ||||||||
| FaxNumber: | 4356743470 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 07/26/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1093699934 | UT | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 999000797009 | 05 | UT | MEDICAID | 87017934025001 | 01 | UT | BLUE CROSS/BLUE SHIELD | OTHER |