Provider Demographics
NPI:1831451681
Name:PETERSON, RANDHI WIJEKULARATNE (MD)
Entity type:Individual
Prefix:DR
First Name:RANDHI
Middle Name:WIJEKULARATNE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:RANDHI
Other - Middle Name:M
Other - Last Name:WIJEKULARATNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 22000
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76902-7200
Mailing Address - Country:US
Mailing Address - Phone:325-658-1511
Mailing Address - Fax:325-481-2166
Practice Address - Street 1:520 S EAGLE RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6351
Practice Address - Country:US
Practice Address - Phone:702-493-9051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-07
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM15216208M00000X
TXQ5902207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXQ5902OtherLICENSE
TX443765YKRYMedicare PIN