Provider Demographics
NPI:1982858874
Name:PEACOCK FOOT CLINIC, PC
Entity Type:Organization
Organization Name:PEACOCK FOOT CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DON
Authorized Official - Middle Name:
Authorized Official - Last Name:PEACOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:910-642-7768
Mailing Address - Street 1:325 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:WHITEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28472-3601
Mailing Address - Country:US
Mailing Address - Phone:910-642-7755
Mailing Address - Fax:910-642-6541
Practice Address - Street 1:409 WILLIAMS ST
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:NC
Practice Address - Zip Code:28337
Practice Address - Country:US
Practice Address - Phone:910-642-7768
Practice Address - Fax:910-642-6541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-05
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC382213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8908003Medicaid
NCU63366Medicare UPIN
NC8908003Medicaid