Provider Demographics
NPI:1861487225
Name:PETERS, CORNELL (MD)
Entity Type:Individual
Prefix:DR
First Name:CORNELL
Middle Name:
Last Name:PETERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 BOWMAN PARK
Mailing Address - Street 2:SUITE A
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-5782
Mailing Address - Country:US
Mailing Address - Phone:478-755-8400
Mailing Address - Fax:478-755-1073
Practice Address - Street 1:2040 BOWMAN PARK
Practice Address - Street 2:SUITE A
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-5782
Practice Address - Country:US
Practice Address - Phone:478-755-8400
Practice Address - Fax:478-755-1073
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2016-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042695207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
08BBTKZMedicare ID - Type Unspecified
F49352Medicare UPIN