Basic Information
| Provider Information | |||||||||
| NPI: | 1114027950 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PECK | ||||||||
| FirstName: | CAROLINE | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 997413 | ||||||||
| Address2: | MS 7213 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958997413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9165529940 | ||||||||
| FaxNumber: | 9165529994 | ||||||||
| Practice Location | |||||||||
| Address1: | 1616 CAPITOL AVE | ||||||||
| Address2: | STE 74.3.84 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958145052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9165529940 | ||||||||
| FaxNumber: | 9165529994 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | A056319 | CA | X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 2083P0901X | A056319 | CA | X | Allopathic & Osteopathic Physicians | Preventive Medicine | Public Health & General Preventive Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01789813 | 05 | NM | MEDICAID | 486896 | 05 | AZ | MEDICAID | 65924843 | 05 | CO | MEDICAID |