Healthcare Provider Details

I. General information

NPI: 1881665461
Provider Name (Legal Business Name): OWEN G PELLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2006
Last Update Date: 07/19/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 NW 84TH AVE STE 200
PLANTATION FL
33324-1847
US

IV. Provider business mailing address

4801 S UNIVERSITY DR STE 104
DAVIE FL
33328-3835
US

V. Phone/Fax

Practice location:
  • Phone: 954-424-4321
  • Fax:
Mailing address:
  • Phone: 954-746-2012
  • Fax: 954-746-2013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME53245
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: