Provider Demographics
NPI:1912205840
Name:PECK, CHARLES A (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:A
Last Name:PECK
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 1:2872 GEMINI LOOP
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80023-4678
Mailing Address - Country:US
Mailing Address - Phone:650-515-6301
Mailing Address - Fax:
Practice Address - Street 1:10901 W 120TH AVE
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80021-3418
Practice Address - Country:US
Practice Address - Phone:720-304-8941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD432063261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHAP2835190OtherDEA