Healthcare Provider Details

I. General information

NPI: 1114954252
Provider Name (Legal Business Name): DR. WALTER PEGOLI JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 06/30/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 ELMWOOD AVE BOX SURG
ROCHESTER NY
14642-8410
US

IV. Provider business mailing address

601 ELMWOOD AVE BOX SURG
ROCHESTER NY
14642-8410
US

V. Phone/Fax

Practice location:
  • Phone: 585-275-4435
  • Fax: 585-273-1252
Mailing address:
  • Phone: 585-275-4435
  • Fax: 585-273-1252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number207965
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: