Healthcare Provider Details

I. General information

NPI: 1073755302
Provider Name (Legal Business Name): CARL CURTIS PECK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2009
Last Update Date: 04/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5955 BALM RIDGE WAY
SAN LUIS OBISPO CA
93401-8024
US

IV. Provider business mailing address

5955 BALM RIDGE WAY
SAN LUIS OBISPO CA
93401-8024
US

V. Phone/Fax

Practice location:
  • Phone: 805-541-2581
  • Fax: 805-547-1226
Mailing address:
  • Phone: 805-541-2581
  • Fax: 805-547-1226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208U00000X
TaxonomyClinical Pharmacology Physician
License NumberG19713
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: