Provider Demographics
NPI:1912937194
Name:PECKHAM, ROGER (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:
Last Name:PECKHAM
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:PO BOX 8792
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-8792
Mailing Address - Country:US
Mailing Address - Phone:440-808-5950
Mailing Address - Fax:440-250-0363
Practice Address - Street 1:29101 HEALTH CAMPUS DR BLDG 2
Practice Address - Street 2:SUITE 295
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-5270
Practice Address - Country:US
Practice Address - Phone:440-808-5950
Practice Address - Fax:440-250-0363
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2020-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-049421207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0903437Medicaid
OH0700125Medicare PIN