=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720085038
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEREK J PEACOCK MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2005
-----------------------------------------------------
Last Update Date | 09/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1305 FOWLER ST STE 1D
-----------------------------------------------------
City | RICHLAND
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99352-4719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-940-2284
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1305 FOWLER ST STE 1D
-----------------------------------------------------
City | RICHLAND
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99352-4719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-940-2284
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RR0500X
-----------------------------------------------------
Taxonomy Name | Rheumatology Physician
-----------------------------------------------------
License Number | MD00036578
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------