Provider Demographics
NPI:1114954252
Name:PEGOLI, WALTER JR
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:
Last Name:PEGOLI
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 ELMWOOD AVE
Mailing Address - Street 2:BOX SURG
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-8410
Mailing Address - Country:US
Mailing Address - Phone:585-275-4435
Mailing Address - Fax:585-273-1252
Practice Address - Street 1:601 ELMWOOD AVE
Practice Address - Street 2:BOX SURG
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642-8410
Practice Address - Country:US
Practice Address - Phone:585-275-4435
Practice Address - Fax:585-273-1252
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2079652086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01741551Medicaid
NY01741551Medicaid
F04597Medicare UPIN