Basic Information
| Provider Information | |||||||||
| NPI: | 1942663224 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEEKSTOK | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D., MPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2111 EXCHANGE ST | ||||||||
| Address2: | |||||||||
| City: | ASTORIA | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971033329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033254321 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2265 EXCHANGE ST | ||||||||
| Address2: | |||||||||
| City: | ASTORIA | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971033331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033257337 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2016 | ||||||||
| LastUpdateDate: | 02/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD196135 | OR | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.