Provider Demographics
NPI:1295721462
Name:PEACOCK, LISA MARIE (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
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 1:3700 SAINT CHARLES AVE
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70115-4637
Mailing Address - Country:US
Mailing Address - Phone:504-412-1520
Mailing Address - Fax:504-899-2866
Practice Address - Street 1:3700 SAINT CHARLES AVE
Practice Address - Street 2:5TH FLOOR
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70115-4637
Practice Address - Country:US
Practice Address - Phone:504-412-1520
Practice Address - Fax:504-899-2866
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033672207V00000X
LA205673207VF0040X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyUrogynecology and Reconstructive Pelvic Surgery
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
16BDTDDMedicare ID - Type Unspecified
LA247697YH3TMedicare PIN
F31619Medicare UPIN