Provider Demographics
NPI:1003020082
Name:PEGGAU, JOHN (PYSD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:PEGGAU
Suffix:
Gender:M
Credentials:PYSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1426 FERNCROFT CT
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-9772
Mailing Address - Country:US
Mailing Address - Phone:630-745-0080
Mailing Address - Fax:815-524-5154
Practice Address - Street 1:1426 FERNCROFT CT
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-9772
Practice Address - Country:US
Practice Address - Phone:630-745-0080
Practice Address - Fax:815-524-5154
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL210626Medicare ID - Type Unspecified