Healthcare Provider Details

I. General information

NPI: 1881763613
Provider Name (Legal Business Name): JOHN EDWARD PEACOCK III D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 06/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10000 SHANNONDELL DR
AUDUBON PA
19403-5615
US

IV. Provider business mailing address

10000 SHANNONDELL DR
AUDUBON PA
19403-5615
US

V. Phone/Fax

Practice location:
  • Phone: 610-728-5241
  • Fax: 610-728-5322
Mailing address:
  • Phone: 610-728-5241
  • Fax: 610-728-5322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberOS014770
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS014770
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: