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General NPI Number Information
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NPI Number | 1700031960
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Entity Type | Individual
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Provider Name | MARK WILLIAM PEGAN D.C.
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Gender | Male
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Dates
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Enumeration Date | 12/01/2008
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Last Update Date | 12/01/2008
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Provider Practice Location Address
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Address Line | 365 WAYMONT CT SUITE 101
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City | LAKE MARY
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State | FL
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Zip | 32746-3552
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Country | US
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Telephone | 407-321-9191
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Fax |
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Provider Business Mailing Address
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Address Line | 1246 GLENCREST DR
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City | HEATHROW
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State | FL
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Zip | 32746-5024
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Country | US
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Telephone | 407-595-7191
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | CH9620
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License Number State | FL
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