Provider Demographics
NPI:1023026176
Name:PECK, MICHAEL LLOYD (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LLOYD
Last Name:PECK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 W MAINE AVE
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73701-5542
Mailing Address - Country:US
Mailing Address - Phone:580-242-2300
Mailing Address - Fax:580-233-7370
Practice Address - Street 1:517 W MAINE AVE
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-5542
Practice Address - Country:US
Practice Address - Phone:580-242-2300
Practice Address - Fax:580-233-7370
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1058152W00000X, 156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK730794467004OtherBCBSOK
OK100765010BMedicaid
OK410001137OtherR.R. MEDICARE
OK0582320001OtherPALMETTO
OKT40604Medicare UPIN
OK0582320001OtherPALMETTO