Healthcare Provider Details

I. General information

NPI: 1306034830
Provider Name (Legal Business Name): MICHAEL L PECK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2007
Last Update Date: 08/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 W MAINE AVE
ENID OK
73701-5542
US

IV. Provider business mailing address

517 W MAINE AVE
ENID OK
73701-5542
US

V. Phone/Fax

Practice location:
  • Phone: 580-242-2300
  • Fax: 580-233-7370
Mailing address:
  • Phone: 580-242-2300
  • Fax: 580-233-7370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1058
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number1058
License Number StateOK

VIII. Authorized Official

Name: DR. MICHAEL L PECK
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 580-242-2300