Provider Demographics
NPI:1629707310
Name:PEAY, DAVID
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:PEAY
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 1:19 JOHN PAUL CT
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14206-1767
Mailing Address - Country:US
Mailing Address - Phone:716-715-0182
Mailing Address - Fax:
Practice Address - Street 1:19 JOHN PAUL CT
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14206-1767
Practice Address - Country:US
Practice Address - Phone:716-715-0182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-08
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY646222266172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05114407Medicaid