Provider Demographics
NPI:1770712424
Name:PECK, MICHAEL SCOTT (DPM)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SCOTT
Last Name:PECK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 KELLY JOHNSON BLVD
Mailing Address - Street 2:#310
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-3932
Mailing Address - Country:US
Mailing Address - Phone:719-574-9800
Mailing Address - Fax:
Practice Address - Street 1:1155 KELLY JOHNSON BLVD
Practice Address - Street 2:#310
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-3932
Practice Address - Country:US
Practice Address - Phone:719-574-9800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-02
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR251213E00000X
COPOD.0000777213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist