Provider Demographics
NPI:1184682106
Name:PEACOCK, JOSEPH RONALD (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:RONALD
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 1:1601 MILLTOWN RD
Mailing Address - Street 2:SUITE 13
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19808-4027
Mailing Address - Country:US
Mailing Address - Phone:302-993-2330
Mailing Address - Fax:302-993-2344
Practice Address - Street 1:1020 N UNION ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19805-2736
Practice Address - Country:US
Practice Address - Phone:302-427-9855
Practice Address - Fax:302-427-9549
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-00019242085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000112301Medicaid
DE00A571G66Medicare PIN
DE063359W26Medicare PIN
DE006950P97Medicare PIN
DE063359O73Medicare PIN
DE003244B93Medicare PIN
DE0000112301Medicaid
DE003994D14Medicare PIN