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General NPI Number Information
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NPI Number | 1346419645
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Entity Type | Organization
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Legal Business Name | MARK D PECKHAM OD PC
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Dates
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Enumeration Date | 02/21/2008
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Last Update Date | 03/05/2008
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Provider Practice Location Address
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Address Line | 600 WESTWOOD
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City | FESTUS
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State | MO
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Zip | 63028-2061
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Country | US
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Telephone | 636-937-4747
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Fax | 636-937-4747
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Provider Business Mailing Address
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Address Line | 600 WESTWOOD
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City | FESTUS
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State | MO
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Zip | 63028-2061
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Country | US
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Telephone | 636-937-4747
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Fax | 636-937-4747
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Authorized Official
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Title or Position | DOCTOR OWNER OPTOMETRIST
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Name | MARK D PECKHAM
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Credential | OD
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Telephone | 636-927-4747
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | TO2158
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License Number State | MO
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