Provider Demographics
NPI:1316717127
Name:PELT, MARCUS I
Entity type:Individual
Prefix:MR
First Name:MARCUS
Middle Name:
Last Name:PELT
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:662 SW EMPIRE ST
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-8775
Mailing Address - Country:US
Mailing Address - Phone:772-203-3122
Mailing Address - Fax:
Practice Address - Street 1:2280 N US1 HWY
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34946
Practice Address - Country:US
Practice Address - Phone:772-203-3122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-03
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife