Provider Demographics
NPI:1316003197
Name:PEDEN, KIRBY WATSON (MD)
Entity Type:Individual
Prefix:DR
First Name:KIRBY
Middle Name:WATSON
Last Name:PEDEN
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 1:420 E 2ND AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-3209
Mailing Address - Country:US
Mailing Address - Phone:706-509-3278
Mailing Address - Fax:
Practice Address - Street 1:420 E 2ND AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-3209
Practice Address - Country:US
Practice Address - Phone:706-509-3278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046208207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTG98519Medicare UPIN