Basic Information
Provider Information | |||||||||
NPI: | 1720085038 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PEACOCK | ||||||||
FirstName: | DEREK | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 560 GAGE BLVD | ||||||||
Address2: | STE 203 | ||||||||
City: | RICHLAND | ||||||||
State: | WA | ||||||||
PostalCode: | 99352 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5099423627 | ||||||||
FaxNumber: | 5099422268 | ||||||||
Practice Location | |||||||||
Address1: | 6710 W OKANOGAN PL | ||||||||
Address2: | KADLEC CLINIC RHEUMATOLOGY | ||||||||
City: | KENNEWICK | ||||||||
State: | WA | ||||||||
PostalCode: | 99336 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5099422528 | ||||||||
FaxNumber: | 5097832008 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/30/2005 | ||||||||
LastUpdateDate: | 06/23/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/23/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RR0500X | MD00036578 | WA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
ID Information
ID | Type | State | Issuer | Description | 0152619 | 01 | WA | L&I | OTHER | 8477630 | 05 | WA |   | MEDICAID | 660003458 | 01 | WA | MEDICARE RR | OTHER |