Provider Demographics
NPI:1023223021
Name:PEACOCK, DENNIS ALAN (MD)
Entity type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:ALAN
Last Name:PEACOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 N. LAKE SHORE DRIVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2987
Mailing Address - Country:US
Mailing Address - Phone:312-695-6868
Mailing Address - Fax:
Practice Address - Street 1:1333 W BELMONT AVE STE 100
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657
Practice Address - Country:US
Practice Address - Phone:312-694-2273
Practice Address - Fax:312-694-1875
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200700207R00000X, 208000000X
IL036.141382208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05024018Medicaid
LA1073849Medicaid
LA1073849Medicaid