MEDICARE: DEREK J PEACOCK MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RR0500X	Rheumatology Physician	MD00036578	WA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	660003458	OTHER	WA	MEDICARE RR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0152619	OTHER	WA	L&I
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720085038
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEREK J PEACOCK MD

Provider Business Mailing Address
First Line	:	1305 FOWLER ST STE 1D
Second Line	:
City	:	RICHLAND
State	:	WA
Zip	:	99352-4719
Country	:	US
Telephone Number	:	509-940-2284
Fax Number	:

Provider Business Practice Location Address
First Line	:	1305 FOWLER ST STE 1D
Second Line	:
City	:	RICHLAND
State	:	WA
Zip	:	99352-4719
Country	:	US
Telephone Number	:	509-940-2284
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2005
Last Update Date	:	09/18/2025

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