Provider Demographics
NPI:1730930298
Name:PETERY, TAYLOR LEE (MD)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:LEE
Last Name:PETERY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:LEE
Other - Last Name:BOGGS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1950 CIRCLE OF HOPE DR RM 1570
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84112-5500
Mailing Address - Country:US
Mailing Address - Phone:801-581-2121
Mailing Address - Fax:937-384-6938
Practice Address - Street 1:1950 CIRCLE OF HOPE DR RM 1570
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84112-5500
Practice Address - Country:US
Practice Address - Phone:801-581-2121
Practice Address - Fax:937-384-6938
Is Sole Proprietor?:No
Enumeration Date:2024-04-01
Last Update Date:2025-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT14244280-12052085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program