Provider Demographics
NPI:1245340322
Name:PEACOCK, MARK ALLEN (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALLEN
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 1:3841 FEATHER OAKS DR E
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32277-2293
Mailing Address - Country:US
Mailing Address - Phone:904-591-8697
Mailing Address - Fax:904-744-8268
Practice Address - Street 1:3841 FEATHER OAKS DR. E.
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32277-2293
Practice Address - Country:US
Practice Address - Phone:904-591-8697
Practice Address - Fax:904-744-8268
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL45325207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine