Healthcare Provider Details

I. General information

NPI: 1588899488
Provider Name (Legal Business Name): CAROLEE MARIE CUTLER PECK M.D., M.P.H.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2009
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3365 CHASEWOOD DRIVE
AMMON ID
83406
US

IV. Provider business mailing address

PO BOX 50678
IDAHO FALLS ID
83405-0678
US

V. Phone/Fax

Practice location:
  • Phone: 208-228-5555
  • Fax: 208-228-0077
Mailing address:
  • Phone: 208-228-5555
  • Fax: 208-228-0077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License NumberM-15305
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: