Organization
PETERSON DERMATOLOGY, P.C.
Active
Organization
PETERSON DERMATOLOGY, P.C.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. LETTY REVELL PETERSON M.D. (DERMATOLOGIST)
(912) 538-9080
Entity
Organization
Contact information
Practice address
305 W 1ST ST, VIDALIA, GA 30474-3302
(912) 538-9080
(912) 538-9085
Mailing address
305 W 1ST ST, VIDALIA, GA 30474-3302
(912) 538-9080
(912) 538-9085
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
058913
GA
207NP0225X
Pediatric Dermatology Physician
058913
GA
207NS0135X
Procedural Dermatology Physician
058913
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
551383524A
—
GA
Enumeration date
05/29/2007
Last updated
09/20/2013
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