Provider Demographics
NPI:1881665461
Name:PELLER, OWEN G (MD)
Entity Type:Individual
Prefix:
First Name:OWEN
Middle Name:G
Last Name:PELLER
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 1:4801 S UNIVERSITY DR
Mailing Address - Street 2:STE 104
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-3835
Mailing Address - Country:US
Mailing Address - Phone:954-746-2012
Mailing Address - Fax:954-746-2013
Practice Address - Street 1:350 NW 84TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-1847
Practice Address - Country:US
Practice Address - Phone:954-424-4321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-31
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME53245207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL371831000Medicaid
FL371831000Medicaid
07540Medicare ID - Type Unspecified