Provider Demographics
NPI:1275793275
Name:PEACOCK, ELIZABETH KAY (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:KAY
Last Name:PEACOCK
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 1:1514 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2429
Mailing Address - Country:US
Mailing Address - Phone:504-842-4000
Mailing Address - Fax:
Practice Address - Street 1:4429 CLARA ST
Practice Address - Street 2:SUITE 600A
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70115-6902
Practice Address - Country:US
Practice Address - Phone:504-371-0071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA206015174400000X
LAMD.206015208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00508323Medicaid
LA2341103Medicaid
LA2341103Medicaid