Provider Demographics
NPI:1902124308
Name:PETERSON, RANDALL ERIK (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:ERIK
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2510
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-2510
Mailing Address - Country:US
Mailing Address - Phone:706-650-7799
Mailing Address - Fax:706-650-9540
Practice Address - Street 1:4039 GATEWAY BLVD
Practice Address - Street 2:
Practice Address - City:GROVETOWN
Practice Address - State:GA
Practice Address - Zip Code:30813-3195
Practice Address - Country:US
Practice Address - Phone:706-922-1600
Practice Address - Fax:706-922-1010
Is Sole Proprietor?:No
Enumeration Date:2010-05-10
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA72759207Q00000X
GA14-036207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine