Provider Demographics
NPI:1821741323
Name:CAROLEE M CUTLER PECK MD MPH OPRS PLLC
Entity Type:Organization
Organization Name:CAROLEE M CUTLER PECK MD MPH OPRS PLLC
Other - Org Name:CUTLER PECK OCULOFACIAL PLASTIC SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROLEE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CUTLER PECK
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH
Authorized Official - Phone:208-201-1817
Mailing Address - Street 1:PO BOX 50678
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83405-0678
Mailing Address - Country:US
Mailing Address - Phone:208-228-5555
Mailing Address - Fax:435-754-7265
Practice Address - Street 1:117 W MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1826
Practice Address - Country:US
Practice Address - Phone:208-228-5555
Practice Address - Fax:208-228-0077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-03
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty