1316049588 NPI number — GAYLON K PETERSON MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316049588 NPI number — GAYLON K PETERSON MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

PETERSON

Provider First Name:

GAYLON

Provider Middle Name:

K

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

M

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1316049588

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

07/08/2007

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

2975 EXECUTIVE PKWY

Provider Second Line Business Mailing Address:

200

Provider Business Mailing Address City Name:

LEHI

Provider Business Mailing Address State Name:

UT

Provider Business Mailing Address Postal Code:

84043-9642

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

801-990-1911

Provider Business Mailing Address Fax Number:

801-990-1912

Provider First Line Business Practice Location Address:

5770 FASHION BLVD

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

MURRAY

Provider Business Practice Location Address State Name:

UT

Provider Business Practice Location Address Postal Code:

84107-6548

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

801-993-9582

Provider Business Practice Location Address Fax Number:

801-733-5618

Provider Enumeration Date:

09/01/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207L00000X , with the licence number:  154069-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 73539 . This is a "PEHP" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: 9969 . This is a "HEALTHY U" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: 2090168 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: 820698 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
• Identifier: QM0000075886 . This is a "ALTIUS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: 87035828609001 . This is a "BCBS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: 1502954 . This is a "UMWA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: TPRA06888 . This is a "MOLINA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: 107006473102 . This is a "IHC" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: 870545614GP2 . This is a "EDUCATORS MUTUAL" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: 36134 . This is a "DESERET MUTUAL" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".