Provider Demographics
NPI:1417299074
Name:PETERSON, GARY L (DVM)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:L
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DVM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-4535
Mailing Address - Country:US
Mailing Address - Phone:801-328-8543
Mailing Address - Fax:801-364-1803
Practice Address - Street 1:1220 S STATE ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-4535
Practice Address - Country:US
Practice Address - Phone:801-328-8543
Practice Address - Fax:801-364-1803
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-21
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT109676-2801174M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174M00000XOther Service ProvidersVeterinarian