Healthcare Provider Details

I. General information

NPI: 1508805573
Provider Name (Legal Business Name): GORDON J PELTIER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 JOHNSON FERRY RD SUITE 100
MARIETTA GA
30068-5425
US

IV. Provider business mailing address

1955 LAKE PARK DR STE. 250
SMYRNA GA
30080
US

V. Phone/Fax

Practice location:
  • Phone: 770-509-1025
  • Fax:
Mailing address:
  • Phone: 678-223-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number015808
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: