Provider Demographics
NPI:1497974711
Name:PETO, RANDOLPH R (MD)
Entity Type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:R
Last Name:PETO
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 1:94 KINGSBURY ST
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02481-4847
Mailing Address - Country:US
Mailing Address - Phone:413-794-4285
Mailing Address - Fax:
Practice Address - Street 1:BAYSTATE MEDICAL CTR
Practice Address - Street 2:759 CHESTNUT STREET
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01199-0001
Practice Address - Country:US
Practice Address - Phone:413-794-4285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA583032083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine