1720085038 NPI number — DEREK J PEACOCK MD

Table of content: DEREK J PEACOCK MD (NPI 1720085038)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720085038 NPI number — DEREK J PEACOCK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEACOCK
Provider First Name:
DEREK
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720085038
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
560 GAGE BLVD
Provider Second Line Business Mailing Address:
STE 203
Provider Business Mailing Address City Name:
RICHLAND
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99352
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-942-3627
Provider Business Mailing Address Fax Number:
509-942-2268

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6710 W OKANOGAN PL
Provider Second Line Business Practice Location Address:
KADLEC CLINIC RHEUMATOLOGY
Provider Business Practice Location Address City Name:
KENNEWICK
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99336
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-942-2528
Provider Business Practice Location Address Fax Number:
509-783-2008
Provider Enumeration Date:
06/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RR0500X , with the licence number:  MD00036578 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0152619 . This is a "L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8477630 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 660003458 . This is a "MEDICARE RR" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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