Healthcare Provider Details

I. General information

NPI: 1679835219
Provider Name (Legal Business Name): JEFFREY PECK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2012
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 WELBORN ST
DALLAS TX
75219-3924
US

IV. Provider business mailing address

2222 WELBORN ST
DALLAS TX
75219-3924
US

V. Phone/Fax

Practice location:
  • Phone: 214-559-8430
  • Fax: 214-559-7570
Mailing address:
  • Phone: 214-559-8430
  • Fax: 214-559-7570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number5315055844
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number4301101089
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License NumberR1104
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: