Provider Demographics
NPI:1467117929
Name:PEGUILLAN, LAURA ANN (OD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:ANN
Last Name:PEGUILLAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13411 PATMORE DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217-1516
Mailing Address - Country:US
Mailing Address - Phone:904-200-2896
Mailing Address - Fax:
Practice Address - Street 1:8222 AGORA PKWY STE 116
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:TX
Practice Address - Zip Code:78154-1319
Practice Address - Country:US
Practice Address - Phone:210-659-1479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-01
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10405152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist