Provider Demographics
NPI:1588953293
Name:PEGUERO, EDWARD (ORTHOTIST)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:PEGUERO
Suffix:
Gender:M
Credentials:ORTHOTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20911 41ST AVE
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-1926
Mailing Address - Country:US
Mailing Address - Phone:551-580-2711
Mailing Address - Fax:718-225-5374
Practice Address - Street 1:8211 37TH AVENUE SUITE LL19
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372
Practice Address - Country:US
Practice Address - Phone:718-255-1986
Practice Address - Fax:718-255-1989
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-04
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier