Provider Demographics
NPI:1730400516
Name:PEACOCK, TODD PHILLIP (MD)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:PHILLIP
Last Name:PEACOCK
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 1:145 KIMEL PARK DR STE 120
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6983
Mailing Address - Country:US
Mailing Address - Phone:336-768-3212
Mailing Address - Fax:
Practice Address - Street 1:145 KIMEL PARK DR STE 120
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103
Practice Address - Country:US
Practice Address - Phone:336-768-3212
Practice Address - Fax:336-768-9019
Is Sole Proprietor?:No
Enumeration Date:2010-06-16
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN52747207L00000X
NC165574390200000X
NC2012-01209207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program