Provider Demographics
NPI:1073893616
Name:PETERSON, JUSTIN (MD)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:
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 1:2010 OCILLA RD
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-2230
Mailing Address - Country:US
Mailing Address - Phone:912-384-2500
Mailing Address - Fax:912-383-6788
Practice Address - Street 1:2010 OCILLA RD
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2230
Practice Address - Country:US
Practice Address - Phone:912-384-2500
Practice Address - Fax:912-383-6788
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-26
Last Update Date:2019-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA079895207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology