Provider Demographics
NPI:1922459866
Name:PEGAN, DOUGLAS J
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:J
Last Name:PEGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 S DALE MABRY HWY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-5019
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1220 S DALE MABRY HWY
Practice Address - Street 2:SUITE 201
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-5019
Practice Address - Country:US
Practice Address - Phone:727-417-4997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-22
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251B00000X104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL011807700Medicaid