Provider Demographics
NPI:1073627022
Name:PEGO, RICHARD FERNANDO (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:FERNANDO
Last Name:PEGO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MR
Other - First Name:SHEL
Other - Middle Name:
Other - Last Name:ROCKLIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:17075 DEVONSHIRE STREET
Mailing Address - Street 2:SUITE 201
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-5407
Mailing Address - Country:US
Mailing Address - Phone:818-365-9595
Mailing Address - Fax:818-365-8955
Practice Address - Street 1:17075 DEVONSHIRE STREET
Practice Address - Street 2:SUITE 201
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-5407
Practice Address - Country:US
Practice Address - Phone:818-365-9595
Practice Address - Fax:818-365-8955
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA33230207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0091580Medicaid
A27082Medicare UPIN
CAGR0091580Medicaid