Healthcare Provider Details

I. General information

NPI: 1720085038
Provider Name (Legal Business Name): DEREK J PEACOCK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 09/18/2025
Certification Date: 09/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 FOWLER ST STE 1D
RICHLAND WA
99352-4719
US

IV. Provider business mailing address

1305 FOWLER ST STE 1D
RICHLAND WA
99352-4719
US

V. Phone/Fax

Practice location:
  • Phone: 509-940-2284
  • Fax:
Mailing address:
  • Phone: 509-940-2284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberMD00036578
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: