Provider Demographics
NPI:1003828542
Name:PEACOCK, LAMAR B (MD)
Entity Type:Individual
Prefix:
First Name:LAMAR
Middle Name:B
Last Name:PEACOCK
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 1:465 N BELAIR RD
Mailing Address - Street 2:SUITE 3A
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-3188
Mailing Address - Country:US
Mailing Address - Phone:706-447-1118
Mailing Address - Fax:706-826-2775
Practice Address - Street 1:465 N BELAIR RD
Practice Address - Street 2:SUITE 3-A
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3188
Practice Address - Country:US
Practice Address - Phone:706-447-1118
Practice Address - Fax:706-826-2775
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034920207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11SCHCPMedicare ID - Type Unspecified
GAF83828Medicare UPIN