Healthcare Provider Details

I. General information

NPI: 1932300886
Provider Name (Legal Business Name): PETERSON DERMATOLOGY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 09/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W 1ST ST
VIDALIA GA
30474-3302
US

IV. Provider business mailing address

305 W 1ST ST
VIDALIA GA
30474-3302
US

V. Phone/Fax

Practice location:
  • Phone: 912-538-9080
  • Fax: 912-538-9085
Mailing address:
  • Phone: 912-538-9080
  • Fax: 912-538-9085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number058913
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number058913
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number058913
License Number StateGA

VIII. Authorized Official

Name: DR. LETTY REVELL PETERSON
Title or Position: DERMATOLOGIST
Credential: M.D.
Phone: 912-538-9080