Provider Demographics
NPI:1972569291
Name:PEGUERO RIVERA, EDWIN NELSON (MD)
Entity type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:NELSON
Last Name:PEGUERO RIVERA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4714 N ARMENIA AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603-2603
Mailing Address - Country:US
Mailing Address - Phone:813-443-6957
Mailing Address - Fax:813-443-4891
Practice Address - Street 1:4714 N ARMENIA AVE STE 202
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33603-2603
Practice Address - Country:US
Practice Address - Phone:813-443-6957
Practice Address - Fax:813-443-4891
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR124762084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRE90247Medicare UPIN
FL15247AMedicare ID - Type UnspecifiedPROVIDER NUMBER
FLE90247Medicare UPIN