Provider Demographics
NPI:1306076021
Name:PEEK, REGINALD DEMETRIUS (MD)
Entity type:Individual
Prefix:
First Name:REGINALD
Middle Name:DEMETRIUS
Last Name:PEEK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2419 LAUREL CIR NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30311-1237
Mailing Address - Country:US
Mailing Address - Phone:404-277-9264
Mailing Address - Fax:
Practice Address - Street 1:950 INDIAN TRL RD NW
Practice Address - Street 2:SUITE 5D
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-1721
Practice Address - Country:US
Practice Address - Phone:404-600-5563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-15
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA063002174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003152731AMedicaid