Provider Demographics
NPI:1801816715
Name:PECKHAM, RUSSELL (DO)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:PECKHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7200 WYOMING SPGS
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78681-4303
Mailing Address - Country:US
Mailing Address - Phone:512-910-8800
Mailing Address - Fax:512-522-4483
Practice Address - Street 1:7200 WYOMING SPGS
Practice Address - Street 2:SUITE 300
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-4303
Practice Address - Country:US
Practice Address - Phone:512-910-8800
Practice Address - Fax:512-522-4483
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2017-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102201303207R00000X
TXP5120207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX349622YMBZMedicare PIN