Provider Demographics
NPI:1467446740
Name:PEACOCK, PHILIP R (DO)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:R
Last Name:PEACOCK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950N GLEBE RD 4000
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22203-1824
Mailing Address - Country:US
Mailing Address - Phone:571-295-7514
Mailing Address - Fax:
Practice Address - Street 1:8100 ASHTON AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109
Practice Address - Country:US
Practice Address - Phone:703-257-8090
Practice Address - Fax:703-257-7822
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102036935207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA05859361Medicaid
080175699OtherRR MEDICARE
VA080007766Medicare PIN
VA05859361Medicaid