Provider Demographics
NPI:1114994233
Name:PELLEGRIN, KATHARINA (MD)
Entity Type:Individual
Prefix:
First Name:KATHARINA
Middle Name:
Last Name:PELLEGRIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4205 BELFORT RD STE 4015
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3623
Mailing Address - Country:US
Mailing Address - Phone:904-450-6014
Mailing Address - Fax:904-450-6401
Practice Address - Street 1:619 N COVE BLVD
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-3642
Practice Address - Country:US
Practice Address - Phone:850-913-6960
Practice Address - Fax:850-913-6961
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2024-04-11
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2008-11-25
Provider Licenses
StateLicense IDTaxonomies
CAA636042086S0105X
VA01012650792086S0127X, 208600000X, 2086S0102X
FLME141879208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA63604Medicaid
CAH54473Medicare UPIN
CAA63604Medicaid