Provider Demographics
NPI:1063563104
Name:PECK, IRVING
Entity type:Individual
Prefix:
First Name:IRVING
Middle Name:
Last Name:PECK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1937 OLD MAIN ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MAYSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41056
Mailing Address - Country:US
Mailing Address - Phone:606-759-7311
Mailing Address - Fax:
Practice Address - Street 1:1937 OLD MAIN ST
Practice Address - Street 2:SUITE 2
Practice Address - City:MAYSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41056
Practice Address - Country:US
Practice Address - Phone:606-759-7311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0396156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY52800976Medicaid
OH0559408Medicaid
KY52903960Medicaid
KY000000077313OtherBCBS