Provider Demographics
NPI:1750380002
Name:PESKOE, STEPHEN M (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:M
Last Name:PESKOE
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 1:920 N SHADELAND AVE
Mailing Address - Street 2:SUITE G1
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4898
Mailing Address - Country:US
Mailing Address - Phone:317-355-9777
Mailing Address - Fax:317-355-9760
Practice Address - Street 1:8075 N SHADELAND AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-2693
Practice Address - Country:US
Practice Address - Phone:317-621-8500
Practice Address - Fax:317-621-8501
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2009-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01025113A207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100260610AMedicaid
IN4004378OtherAETNA
INP00719555Medicare PIN
IN248520AMedicare PIN
IN060029985Medicare PIN
IN100260610AMedicaid
INC25893Medicare UPIN