Provider Demographics
NPI:1205584224
Name:PEGRAM, CHRISTOPHER TODD II (CSFA)
Entity type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:TODD
Last Name:PEGRAM
Suffix:II
Gender:M
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5423 BLUE DOG RD
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32404-6032
Mailing Address - Country:US
Mailing Address - Phone:940-230-7059
Mailing Address - Fax:
Practice Address - Street 1:1202 E ARAPAHO RD STE 122
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75081-2400
Practice Address - Country:US
Practice Address - Phone:469-250-4422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-17
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL202654208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP265-118-91-177-0OtherCSFA