Provider Demographics
NPI:1659743334
Name:PEACOCK, STEPHANIE OLGA (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:OLGA
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 63112
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28263-3112
Mailing Address - Country:US
Mailing Address - Phone:336-274-9617
Mailing Address - Fax:336-482-2177
Practice Address - Street 1:1331 N ELM ST STE 200
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-6304
Practice Address - Country:US
Practice Address - Phone:336-274-9617
Practice Address - Fax:336-482-2177
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-21
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21931207R00000X
NC2019-009252085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine