Provider Demographics
NPI:1376508135
Name:PEACOCK, MUNRO (MD)
Entity Type:Individual
Prefix:
First Name:MUNRO
Middle Name:
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 44994
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46244-0994
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:541 CLINICAL DR
Practice Address - Street 2:CL 365
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5111
Practice Address - Country:US
Practice Address - Phone:317-274-4359
Practice Address - Fax:317-274-4311
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01035819207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100128860Medicaid
IN264910F7Medicare PIN
IN100128860Medicaid