Provider Demographics
NPI:1427467208
Name:PETERSEN, MATHEW (ABOC)
Entity type:Individual
Prefix:
First Name:MATHEW
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9450 S 1300 E
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-5555
Mailing Address - Country:US
Mailing Address - Phone:801-576-6433
Mailing Address - Fax:801-576-5643
Practice Address - Street 1:9450 S 1300 E
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-5555
Practice Address - Country:US
Practice Address - Phone:801-576-6433
Practice Address - Fax:801-576-5643
Is Sole Proprietor?:No
Enumeration Date:2014-08-06
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician