Provider Demographics
NPI:1215018403
Name:PECK, KIMBERLY A (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
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 1:550 WASHINGTON ST STE 641
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2229
Mailing Address - Country:US
Mailing Address - Phone:619-299-2600
Mailing Address - Fax:619-299-3923
Practice Address - Street 1:550 WASHINGTON ST STE 641
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2229
Practice Address - Country:US
Practice Address - Phone:619-299-2600
Practice Address - Fax:619-299-3923
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33630208600000X, 2086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ954075Medicaid
I36825Medicare UPIN
104545Medicare ID - Type Unspecified