Provider Demographics
NPI:1487857082
Name:PEACOCK, SETH (MD)
Entity Type:Individual
Prefix:DR
First Name:SETH
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 1:6141 BURLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-2409
Mailing Address - Country:US
Mailing Address - Phone:303-717-3329
Mailing Address - Fax:
Practice Address - Street 1:6141 BURLINGTON AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-2409
Practice Address - Country:US
Practice Address - Phone:303-717-3329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-09
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11013309A146D00000X
CODR.0051730207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant