Provider Demographics
NPI:1427317783
Name:CHARLES JEFFERY PECK, DO, PC
Entity type:Organization
Organization Name:CHARLES JEFFERY PECK, DO, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:JEFFERY
Authorized Official - Last Name:PECK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:719-640-4007
Mailing Address - Street 1:4641 BRIDLE PASS DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80923-9266
Mailing Address - Country:US
Mailing Address - Phone:719-640-4007
Mailing Address - Fax:
Practice Address - Street 1:4641 BRIDLE PASS DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80923-9266
Practice Address - Country:US
Practice Address - Phone:719-640-4007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-08
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO40851103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COI09932Medicare UPIN