Provider Demographics
NPI:1427546738
Name:PEGUEROS, JUSTIN ALEXANDER (MD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ALEXANDER
Last Name:PEGUEROS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2333 FOOTHILL BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-3027
Mailing Address - Country:US
Mailing Address - Phone:909-392-6501
Mailing Address - Fax:909-469-2136
Practice Address - Street 1:2333 FOOTHILL BLVD STE B
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-3027
Practice Address - Country:US
Practice Address - Phone:909-392-6501
Practice Address - Fax:909-469-2136
Is Sole Proprietor?:No
Enumeration Date:2018-04-23
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA165167207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1427546738Medicaid