Provider Demographics
NPI:1992144364
Name:SPRINGVILLE DERMATOLOGY & DIAGNOSTICS PC
Entity type:Organization
Organization Name:SPRINGVILLE DERMATOLOGY & DIAGNOSTICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:WARREN
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:801-704-7001
Mailing Address - Street 1:732 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84663-1034
Mailing Address - Country:US
Mailing Address - Phone:801-704-7001
Mailing Address - Fax:801-210-7012
Practice Address - Street 1:732 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGVILLE
Practice Address - State:UT
Practice Address - Zip Code:84663-1034
Practice Address - Country:US
Practice Address - Phone:801-704-7001
Practice Address - Fax:801-210-7012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-19
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT72474631204207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty