Provider Demographics
NPI:1356579585
Name:PEACOCK, MARIANNE LYNN RAVERT (DPM)
Entity type:Individual
Prefix:
First Name:MARIANNE
Middle Name:LYNN RAVERT
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 W TOWNSHIP LINE RD
Mailing Address - Street 2:
Mailing Address - City:HAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19083-5215
Mailing Address - Country:US
Mailing Address - Phone:610-449-3344
Mailing Address - Fax:610-449-1325
Practice Address - Street 1:2800 W TOWNSHIP LINE RD
Practice Address - Street 2:
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-5215
Practice Address - Country:US
Practice Address - Phone:610-449-3344
Practice Address - Fax:610-449-1325
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC006134213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery