Provider Demographics
NPI:1750373395
Name:PECKHAM, RICHARD WORTH (MD)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:WORTH
Last Name:PECKHAM
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 1:412 N VINE
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71753-2842
Mailing Address - Country:US
Mailing Address - Phone:870-234-7500
Mailing Address - Fax:870-234-8225
Practice Address - Street 1:715 N COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-4403
Practice Address - Country:US
Practice Address - Phone:870-862-7921
Practice Address - Fax:870-864-2490
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR3207207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR107709001/152144002Medicaid
AR5M688Medicare ID - Type Unspecified
AR107709001/152144002Medicaid