Provider Demographics
NPI:1992539308
Name:PEGRAM, DARNELL ANTONIO JR
Entity type:Individual
Prefix:MR
First Name:DARNELL
Middle Name:ANTONIO
Last Name:PEGRAM
Suffix:JR
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 1:1114 GOLDENEYE DR
Mailing Address - Street 2:
Mailing Address - City:BLACKLICK
Mailing Address - State:OH
Mailing Address - Zip Code:43004-7001
Mailing Address - Country:US
Mailing Address - Phone:614-318-9788
Mailing Address - Fax:
Practice Address - Street 1:2211 LAKE CLUB DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43232-3204
Practice Address - Country:US
Practice Address - Phone:614-318-9788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health