Provider Demographics
NPI:1215268776
Name:PEGASUS PEDIATRICS PA
Entity type:Organization
Organization Name:PEGASUS PEDIATRICS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:LIGHTFOOT
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-584-5780
Mailing Address - Street 1:2810 THOUSAND OAKS DR
Mailing Address - Street 2:#165
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-4108
Mailing Address - Country:US
Mailing Address - Phone:210-912-8395
Mailing Address - Fax:516-214-8751
Practice Address - Street 1:6406 N NEW BRAUNFELS AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-3827
Practice Address - Country:US
Practice Address - Phone:215-584-5780
Practice Address - Fax:516-214-8751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-23
Last Update Date:2010-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM9015208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty