Provider Demographics
NPI:1073508362
Name:PECK, LAUREN A (MD)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:A
Last Name:PECK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:A
Other - Last Name:SHAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4370 WOODLANDS PL
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45241-2441
Mailing Address - Country:US
Mailing Address - Phone:513-563-0044
Mailing Address - Fax:513-563-0061
Practice Address - Street 1:11258 LEBANON RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45241-2214
Practice Address - Country:US
Practice Address - Phone:513-563-0044
Practice Address - Fax:513-563-0061
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-06-4930208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0919537Medicaid