Provider Demographics
NPI:1700031960
Name:PEGAN, MARK WILLIAM (DC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:WILLIAM
Last Name:PEGAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1246 GLENCREST DR
Mailing Address - Street 2:
Mailing Address - City:HEATHROW
Mailing Address - State:FL
Mailing Address - Zip Code:32746-5024
Mailing Address - Country:US
Mailing Address - Phone:407-595-7191
Mailing Address - Fax:
Practice Address - Street 1:365 WAYMONT CT
Practice Address - Street 2:SUITE 101
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3552
Practice Address - Country:US
Practice Address - Phone:407-321-9191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-01
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9620111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor