Provider Demographics
NPI:1003049743
Name:JACQUELINE B PEVNY MD PA
Entity Type:Organization
Organization Name:JACQUELINE B PEVNY MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACQELINE
Authorized Official - Middle Name:B
Authorized Official - Last Name:PEVNY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-272-4888
Mailing Address - Street 1:2040 ALTA MEADOWS LN
Mailing Address - Street 2:SUITE 1601
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33444-1171
Mailing Address - Country:US
Mailing Address - Phone:561-272-4888
Mailing Address - Fax:
Practice Address - Street 1:2040 ALTA MEADOWS LN
Practice Address - Street 2:SUITE 1601
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33444-1171
Practice Address - Country:US
Practice Address - Phone:561-272-4888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-28
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME813822084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH06135Medicare UPIN