Provider Demographics
NPI:1649205956
Name:PEAVY, TODD ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:ALLEN
Last Name:PEAVY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:501 DR MICHAEL DEBAKEY DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-5724
Mailing Address - Country:US
Mailing Address - Phone:337-475-2252
Mailing Address - Fax:337-475-2253
Practice Address - Street 1:1920 W SALE RD
Practice Address - Street 2:BLDG F SUITE 1
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-2400
Practice Address - Country:US
Practice Address - Phone:337-475-2253
Practice Address - Fax:337-475-2253
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA024836207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1430501Medicaid
5H4577460Medicare PIN
P00417424Medicare PIN
LAH19854Medicare UPIN