Provider Demographics
NPI:1063681005
Name:PECK, HEATHER RAE (MD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:RAE
Last Name:PECK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2805 5TH ST STE 210
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-7330
Mailing Address - Country:US
Mailing Address - Phone:605-343-2267
Mailing Address - Fax:
Practice Address - Street 1:2805 5TH ST STE 210
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7330
Practice Address - Country:US
Practice Address - Phone:605-343-2267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036139839207ND0900X
NE23465207ZP0102X
IA40437207ZP0102X
MN55747207ZP0102X
SD8411207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS3026Medicare PIN
SDS34Medicare PIN