Provider Demographics
NPI:1619002821
Name:MAGNUSSON, PEGGY GRAY (DPM)
Entity Type:Individual
Prefix:DR
First Name:PEGGY
Middle Name:GRAY
Last Name:MAGNUSSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:MRS
Other - First Name:PEGGY
Other - Middle Name:GRAY
Other - Last Name:NIMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
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:310-245-2789
Mailing Address - Fax:866-257-3292
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
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2343213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE2343Medicare ID - Type Unspecified
CAT11297Medicare UPIN