Provider Demographics
NPI:1275507071
Name:PEACOCK, JON A (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:A
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:PO BOX 3128
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51102-3128
Mailing Address - Country:US
Mailing Address - Phone:712-239-4702
Mailing Address - Fax:712-224-5898
Practice Address - Street 1:5885 SUNNYBROOK DR
Practice Address - Street 2:SUITE L-200
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51106-4203
Practice Address - Country:US
Practice Address - Phone:712-239-4702
Practice Address - Fax:712-224-5898
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD-31117207RC0000X
NE20074207RC0000X
SD4330207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0135103Medicaid
IA41244Medicare PIN
IA41341Medicare PIN
IA42844Medicare PIN
IA41294Medicare PIN
IA41314Medicare PIN
IA41305Medicare PIN
E36131Medicare UPIN
IA41378Medicare PIN
IA41285Medicare PIN
IA41350Medicare PIN
IA41369Medicare PIN
IA41396Medicare PIN
IA41025Medicare PIN
IA41257Medicare PIN
IA41267Medicare PIN
IA41323Medicare PIN
IA41205Medicare PIN
NE269450Medicare PIN
IA41233Medicare PIN
IA42844Medicare PIN