Provider Demographics
NPI:1720085038
Name:PEACOCK, DEREK J (MD)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:J
Last Name:PEACOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 FOWLER ST STE 1D
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-4719
Mailing Address - Country:US
Mailing Address - Phone:509-940-2284
Mailing Address - Fax:
Practice Address - Street 1:1305 FOWLER ST STE 1D
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-4719
Practice Address - Country:US
Practice Address - Phone:509-940-2284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2025-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00036578207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0152619OtherL&I
WA8477630Medicaid
WA660003458OtherMEDICARE RR
WA660003458OtherMEDICARE RR
WAG18710Medicare UPIN