Provider Demographics
NPI:1902864762
Name:PEACOCK, PENNY JEAN (MD)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:JEAN
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:PENNY
Other - Middle Name:JEAN
Other - Last Name:PEACOCK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD,FAAP
Mailing Address - Street 1:1612 UTE BLVD
Mailing Address - Street 2:205
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-7500
Mailing Address - Country:US
Mailing Address - Phone:435-655-3309
Mailing Address - Fax:435-655-3392
Practice Address - Street 1:1612 UTE BLVD
Practice Address - Street 2:205
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-7500
Practice Address - Country:US
Practice Address - Phone:435-655-3309
Practice Address - Fax:435-655-3392
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3764531205207R00000X, 208000000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTH66409Medicare UPIN
UT005754001Medicare ID - Type UnspecifiedMEDICARE