1184733255 NPI number — PETER PEGOLO OD

Table of content: PETER PEGOLO OD (NPI 1184733255)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184733255 NPI number — PETER PEGOLO OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEGOLO
Provider First Name:
PETER
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184733255
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/26/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
612 QUAKER LN S
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
WEST HARTFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06110-1027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-236-1218
Provider Business Mailing Address Fax Number:
860-231-9298

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
612 QUAKER LN S
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
WEST HARTFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06110-1027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-236-1218
Provider Business Practice Location Address Fax Number:
860-231-9298
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  CT02448 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2V5586 . This is a "HEALTH NET" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5094583 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 002448 . This is a "CONNECTICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 090002448CT02 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1749886 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 203912450 . This is a "UNITED HEALTH CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 203912450 . This is a "VISION SERVICE PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 522108187187 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".




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