Provider Demographics
NPI:1013062306
Name:PECK, MARIE MADONNA (OD)
Entity Type:Individual
Prefix:DR
First Name:MARIE
Middle Name:MADONNA
Last Name:PECK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2169 14TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97322-8510
Mailing Address - Country:US
Mailing Address - Phone:541-967-8730
Mailing Address - Fax:541-926-5465
Practice Address - Street 1:2169 14TH AVE SE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97322-8510
Practice Address - Country:US
Practice Address - Phone:541-967-8730
Practice Address - Fax:541-926-5465
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2821T152W00000X, 152WC0802X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics