Provider Demographics
NPI:1063666139
Name:OWEN PELLER MD LLC
Entity Type:Organization
Organization Name:OWEN PELLER MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGRM
Authorized Official - Prefix:
Authorized Official - First Name:OWEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PELLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-476-6587
Mailing Address - Street 1:10625 NW 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-1707
Mailing Address - Country:US
Mailing Address - Phone:954-476-6587
Mailing Address - Fax:
Practice Address - Street 1:10625 NW 3RD ST
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-1707
Practice Address - Country:US
Practice Address - Phone:954-476-6587
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-16
Last Update Date:2008-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME53245207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty