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General NPI Number Information
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NPI Number | 1902124308
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Entity Type | Individual
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Provider Name | RANDALL ERIK PETERSON M.D.
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Gender | Male
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Dates
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Enumeration Date | 05/10/2010
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Last Update Date | 03/21/2024
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Provider Practice Location Address
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Address Line | 4039 GATEWAY BLVD
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City | GROVETOWN
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State | GA
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Zip | 30813-3195
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Country | US
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Telephone | 706-922-1600
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Fax | 706-922-1010
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Provider Business Mailing Address
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Address Line | PO BOX 2510
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City | EVANS
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State | GA
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Zip | 30809-2510
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Country | US
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Telephone | 706-650-7799
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Fax | 706-650-9540
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 72759
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 14-036
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License Number State | GA
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