Provider Demographics
NPI:1396228441
Name:PEACOCK, RONALD DAVID JR (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:DAVID
Last Name:PEACOCK
Suffix:JR
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 N CAMINO MERCADO STE 26
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-5757
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:580 N CAMINO MERCADO # 26
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-5757
Practice Address - Country:US
Practice Address - Phone:855-331-7522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-13
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPT-30215225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist