Healthcare Provider Details

I. General information

NPI: 1790797108
Provider Name (Legal Business Name): JOANNE PECK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 DOCTORS CIR SUITE 3
SUPPLY NC
28462-4097
US

IV. Provider business mailing address

14 DOCTORS CIR SUITE 3
SUPPLY NC
28462-4097
US

V. Phone/Fax

Practice location:
  • Phone: 910-754-7075
  • Fax: 910-754-2158
Mailing address:
  • Phone: 910-754-7075
  • Fax: 910-754-2158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number200101262
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: