Provider Demographics
NPI:1639104045
Name:PECK, REBECCA L (OD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:PECK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 SO 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IA
Mailing Address - Zip Code:52732
Mailing Address - Country:US
Mailing Address - Phone:563-242-0223
Mailing Address - Fax:563-242-6864
Practice Address - Street 1:425 SO 2ND ST
Practice Address - Street 2:MIDWEST VISION CLINIC PLC
Practice Address - City:CLINTON
Practice Address - State:IA
Practice Address - Zip Code:52732
Practice Address - Country:US
Practice Address - Phone:563-242-0223
Practice Address - Fax:563-242-6864
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01960152W00000X
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1078253Medicaid
IA48078OtherBCBS
IA48078Medicare PIN
IA48078OtherBCBS