Provider Demographics
NPI:1851451462
Name:PEACOCK, WILLIAM STAN (OD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:STAN
Last Name:PEACOCK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2255 HIGHWAY 71
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32448-2541
Mailing Address - Country:US
Mailing Address - Phone:850-526-0067
Mailing Address - Fax:850-526-0069
Practice Address - Street 1:2255 HIGHWAY 71
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32448-2541
Practice Address - Country:US
Practice Address - Phone:850-526-0067
Practice Address - Fax:850-526-0069
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1999152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078363300Medicaid
FL19887OtherBLUE CROSS BLUE SHIELD
FL410029707OtherRAILROAD MEDICARE
FLT93925Medicare UPIN
FL078363300Medicaid