Provider Demographics
NPI:1184694739
Name:PETERSON, RANDALL WATSON (MD)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:WATSON
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 1:3952 TEAYS VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-8728
Mailing Address - Country:US
Mailing Address - Phone:304-757-6736
Mailing Address - Fax:304-757-0582
Practice Address - Street 1:3952 TEAYS VALLEY RD
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-8728
Practice Address - Country:US
Practice Address - Phone:304-757-6736
Practice Address - Fax:304-757-0582
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV14044207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0057148000Medicaid
WV0057148000Medicaid