Provider Demographics
NPI:1407898539
Name:PECK, MICHAEL GLEN JR (IDC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:GLEN
Last Name:PECK
Suffix:JR
Gender:M
Credentials:IDC
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Mailing Address - Street 1:86-227 MOELUA ST
Mailing Address - Street 2:
Mailing Address - City:WAIANAE
Mailing Address - State:HI
Mailing Address - Zip Code:96792-4417
Mailing Address - Country:US
Mailing Address - Phone:808-696-4373
Mailing Address - Fax:
Practice Address - Street 1:822 CLARK ST
Practice Address - Street 2:SUITE 400
Practice Address - City:PEARL HARBOR
Practice Address - State:HI
Practice Address - Zip Code:96860-4652
Practice Address - Country:US
Practice Address - Phone:808-473-1094
Practice Address - Fax:808-473-3109
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman