Provider Demographics
NPI:1922210426
Name:PECK, CHARLES JEFFERY (DO)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:JEFFERY
Last Name:PECK
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 1:2135 SOUTHGATE ROAD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-2605
Mailing Address - Country:US
Mailing Address - Phone:719-329-5353
Mailing Address - Fax:719-578-5407
Practice Address - Street 1:2135 SOUTHGATE ROAD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-2605
Practice Address - Country:US
Practice Address - Phone:719-329-5353
Practice Address - Fax:719-578-5407
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO408512084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
COI09932Medicare UPIN