Healthcare Provider Details

I. General information

NPI: 1902124308
Provider Name (Legal Business Name): RANDALL ERIK PETERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2010
Last Update Date: 03/21/2024
Certification Date: 03/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4039 GATEWAY BLVD
GROVETOWN GA
30813-3195
US

IV. Provider business mailing address

PO BOX 2510
EVANS GA
30809-2510
US

V. Phone/Fax

Practice location:
  • Phone: 706-922-1600
  • Fax: 706-922-1010
Mailing address:
  • Phone: 706-650-7799
  • Fax: 706-650-9540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number72759
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number14-036
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: