Provider Demographics
NPI:1972552107
Name:PETERSON, JEFFREY JUSTIN (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:JUSTIN
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 1:5605 GLENRIDGE DR STE 325
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1365
Mailing Address - Country:US
Mailing Address - Phone:678-553-7783
Mailing Address - Fax:678-553-7793
Practice Address - Street 1:1000 JOHNSON FERRY RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342
Practice Address - Country:US
Practice Address - Phone:404-851-6323
Practice Address - Fax:404-303-3747
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN475552085R0202X
GA0668832085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP00252409OtherRAILROAD MEDICARE
MN16-03566OtherMEDICA
WIP00285261OtherRAILROAD MEDICARE
MN171P6PEOtherBLUE CROSS/BLUE SHIELD OF MN
IA0592113Medicaid
MN1935877OtherAMERICA'S PPO
MN390400800Medicaid
WI34649100Medicaid
MN9249279OtherDAKOTA CARE
MNHP52064OtherHEALTHPARTNERS
MN135108OtherUCARE
MN135108OtherUCARE
MN16-03566OtherMEDICA
MN300003661Medicare PIN
WI005004070Medicare PIN
MN9249279OtherDAKOTA CARE
MNI09256Medicare UPIN