Provider Demographics
NPI:1437554623
Name:WILLIAM PEACOCK
Entity Type:Organization
Organization Name:WILLIAM PEACOCK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:STAN
Authorized Official - Last Name:PEACOCK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:850-526-0067
Mailing Address - Street 1:2255 HIGHWAY 71
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32448-2541
Mailing Address - Country:US
Mailing Address - Phone:850-526-0067
Mailing Address - Fax:850-526-0069
Practice Address - Street 1:2255 HIGHWAY 71
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32448-2541
Practice Address - Country:US
Practice Address - Phone:850-526-0067
Practice Address - Fax:850-526-0069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-30
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1999152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOPC1999OtherOPTOMETRY BRANCH LICENSE