Provider Demographics
NPI:1215956750
Name:PECK, AMANDA DIANE (MD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:DIANE
Last Name:PECK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6055 SW BALD EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:PALM CITY
Mailing Address - State:FL
Mailing Address - Zip Code:34990-8862
Mailing Address - Country:US
Mailing Address - Phone:772-283-7523
Mailing Address - Fax:
Practice Address - Street 1:3573 SW CORPORATE PKWY
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990-8153
Practice Address - Country:US
Practice Address - Phone:772-283-5431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME89635208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL377282901Medicaid
FL377282901Medicaid