Basic Information
| Provider Information | |||||||||
| NPI: | 1508805573 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PELTIER | ||||||||
| FirstName: | GORDON | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1955 LAKE PARK DR | ||||||||
| Address2: | STE. 250 | ||||||||
| City: | SMYRNA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782237700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1121 JOHNSON FERRY RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300685425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705091025 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2006 | ||||||||
| LastUpdateDate: | 10/28/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 015808 | GA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00255802B | 05 | GA | MEDICAID |