Provider Demographics
NPI:1275726499
Name:DR PEGGY G MAGNUSSON
Entity Type:Organization
Organization Name:DR PEGGY G MAGNUSSON
Other - Org Name:MANHATTAN BEACH FOOT & ANKLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:G
Authorized Official - Last Name:MAGNUSSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:310-545-9445
Mailing Address - Street 1:2850 ARTESIA BLVD
Mailing Address - Street 2:#204
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-3419
Mailing Address - Country:US
Mailing Address - Phone:310-545-9445
Mailing Address - Fax:310-545-4998
Practice Address - Street 1:2850 ARTESIA BLVD
Practice Address - Street 2:#204
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90278-3419
Practice Address - Country:US
Practice Address - Phone:310-545-9445
Practice Address - Fax:310-545-4998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-21
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2343332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT11297Medicare UPIN