Provider Demographics
NPI:1508810367
Name:PECK, WALLACE W (MD)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:W
Last Name:PECK
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:DEPT LA 21555
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91185-1555
Mailing Address - Country:US
Mailing Address - Phone:949-764-5570
Mailing Address - Fax:949-263-1639
Practice Address - Street 1:ONE HOAG DRIVE
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-4162
Practice Address - Country:US
Practice Address - Phone:949-764-5570
Practice Address - Fax:949-263-0473
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG528102085N0700X, 2085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G528100OtherBLUE SHIELD
CA00G528100Medicaid
CA00G528100Medicaid
CAWG52810HMedicare PIN
A52354Medicare UPIN
CAWG52810IMedicare PIN