Healthcare Provider Details

I. General information

NPI: 1043215759
Provider Name (Legal Business Name): SCOTT H PETERMANN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 09/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4380 KINGS WAY
VALDOSTA GA
31602-6921
US

IV. Provider business mailing address

4380 KINGS WAY
VALDOSTA GA
31602-6921
US

V. Phone/Fax

Practice location:
  • Phone: 229-391-4180
  • Fax: 229-391-4392
Mailing address:
  • Phone: 229-244-2068
  • Fax: 229-391-4392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number42106
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number42106
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: