Provider Demographics
NPI:1861645921
Name:PECK, EVAN R (MD)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:R
Last Name:PECK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:525 OKEECHOBEE BLVD
Mailing Address - Street 2:14TH FLOOR
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33401-6349
Mailing Address - Country:US
Mailing Address - Phone:561-804-0200
Mailing Address - Fax:561-804-0222
Practice Address - Street 1:525 OKEECHOBEE BLVD
Practice Address - Street 2:14TH FLOOR
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-6349
Practice Address - Country:US
Practice Address - Phone:561-804-0200
Practice Address - Fax:561-804-0222
Is Sole Proprietor?:No
Enumeration Date:2008-11-02
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
390200000X
MN104554208100000X
MN52325208100000X
FLME 1064492081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MNENROLLEDMedicaid