Provider Demographics
NPI:1730174129
Name:PECK, LARRY DON (OD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:DON
Last Name:PECK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 AVENUE G
Mailing Address - Street 2:
Mailing Address - City:FORT MADISON
Mailing Address - State:IA
Mailing Address - Zip Code:52627-2927
Mailing Address - Country:US
Mailing Address - Phone:319-372-2321
Mailing Address - Fax:319-372-2850
Practice Address - Street 1:716 AVENUE G
Practice Address - Street 2:
Practice Address - City:FORT MADISON
Practice Address - State:IA
Practice Address - Zip Code:52627-2927
Practice Address - Country:US
Practice Address - Phone:319-372-2321
Practice Address - Fax:319-372-2850
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1719152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2900894Medicaid
IA24695Medicare ID - Type Unspecified
IAT01041Medicare UPIN
IA2900894Medicaid