Healthcare Provider Details

I. General information

NPI: 1609322395
Provider Name (Legal Business Name): EMIL SURIEL PEGUERO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2016
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date: 03/30/2023
Reactivation Date: 04/11/2023

III. Provider practice location address

697 THOMAS LN
COLUMBUS OH
43214-3931
US

IV. Provider business mailing address

697 THOMAS LN
COLUMBUS OH
43214-3931
US

V. Phone/Fax

Practice location:
  • Phone: 614-566-5414
  • Fax: 614-533-0433
Mailing address:
  • Phone: 614-566-5414
  • Fax: 614-533-0433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: