Provider Demographics
NPI:1306034830
Name:MICHAEL L PECK
Entity Type:Organization
Organization Name:MICHAEL L PECK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:PECK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:580-242-2300
Mailing Address - Street 1:517 W MAINE AVE
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73701-5542
Mailing Address - Country:US
Mailing Address - Phone:580-242-2300
Mailing Address - Fax:580-233-7370
Practice Address - Street 1:517 W MAINE AVE
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-5542
Practice Address - Country:US
Practice Address - Phone:580-242-2300
Practice Address - Fax:580-233-7370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-10
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1058152W00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK410001137OtherRAILROAD MEICARE
OKDA7479OtherRAILROAD MEDICARE GROUP
OK800522342OtherMEDICARE GROUP
OK100765010BMedicaid
730794467004OtherBLUECROSS BLUESHEILD
OK800522342OtherMEDICARE GROUP
OKDA7479OtherRAILROAD MEDICARE GROUP
OK100765010BMedicaid