Provider Demographics
NPI:1316978687
Name:PETERSON, BRIAN R (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:R
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3584 W 9000 S
Mailing Address - Street 2:SUITE 311
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-5710
Mailing Address - Country:US
Mailing Address - Phone:801-566-8304
Mailing Address - Fax:801-566-8304
Practice Address - Street 1:3584 W 9000 S
Practice Address - Street 2:SUITE 311
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-5710
Practice Address - Country:US
Practice Address - Phone:801-566-8304
Practice Address - Fax:801-566-8304
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036142390207Y00000X
UT313974-1205207YX0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & Neurotology
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214881OtherMEDICARE GROUP PTAN
F61008Medicare UPIN