Provider Demographics
NPI:1629036868
Name:PECK, BRIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
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 1:1389 W MAIN ST
Mailing Address - Street 2:SUITE 120
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-3104
Mailing Address - Country:US
Mailing Address - Phone:203-755-5555
Mailing Address - Fax:203-573-8523
Practice Address - Street 1:1389 W MAIN ST
Practice Address - Street 2:SUITE 120
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-3104
Practice Address - Country:US
Practice Address - Phone:203-755-5555
Practice Address - Fax:203-573-8523
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT016893207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004085636Medicaid
CT820000010Medicare ID - Type Unspecified
CT004085636Medicaid