Provider Demographics
NPI:1174614457
Name:PETERSON, RONALD GREGORY (MD)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:GREGORY
Last Name:PETERSON
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:PO BOX 631568
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21263-1568
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6569 N CHARLES ST
Practice Address - Street 2:STE 307
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21204-6831
Practice Address - Country:US
Practice Address - Phone:443-849-2767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD09481207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS140/0004OtherCAREFIRST REGIONAL
MDKJ43GY/346460-03OtherCAREFIRST MARYLAND
D76565Medicare UPIN
MDKJ43GY/346460-03OtherCAREFIRST MARYLAND