Healthcare Provider Details

I. General information

NPI: 1730760307
Provider Name (Legal Business Name): BRAD LEE PECK DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2021
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6070 S FORT APACHE RD STE 100
LAS VEGAS NV
89148-5615
US

IV. Provider business mailing address

6070 S FORT APACHE RD STE 100
LAS VEGAS NV
89148-5615
US

V. Phone/Fax

Practice location:
  • Phone: 702-803-5534
  • Fax:
Mailing address:
  • Phone: 702-803-5534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number2104
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number889
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number887
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: