Provider Demographics
NPI:1720085038
Name:PEACOCK, DEREK J (MD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:J
Last Name:PEACOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:560 GAGE BLVD
Mailing Address - Street 2:STE 203
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352
Mailing Address - Country:US
Mailing Address - Phone:509-942-3627
Mailing Address - Fax:509-942-2268
Practice Address - Street 1:6710 W OKANOGAN PL
Practice Address - Street 2:KADLEC CLINIC RHEUMATOLOGY
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336
Practice Address - Country:US
Practice Address - Phone:509-942-2528
Practice Address - Fax:509-783-2008
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2021-06-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00036578207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0152619OtherL&I
WA8477630Medicaid
WA660003458OtherMEDICARE RR
WA660003458OtherMEDICARE RR
WAG18710Medicare UPIN