Provider Demographics
NPI:1942287271
Name:PEACOCK, BRENDA S (MD)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:S
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 BROWN ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889-4671
Mailing Address - Country:US
Mailing Address - Phone:252-946-6544
Mailing Address - Fax:252-975-6540
Practice Address - Street 1:1204 BROWN ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-4671
Practice Address - Country:US
Practice Address - Phone:252-946-6544
Practice Address - Fax:252-975-6540
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2012-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC32556207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8966356Medicaid
NC8966356Medicaid
213040Medicare ID - Type Unspecified