Provider Demographics
NPI:1942574314
Name:PEGRAM, PATRICIA DIANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:DIANNE
Last Name:PEGRAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2003 CADDINGTON DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-2012
Mailing Address - Country:US
Mailing Address - Phone:310-514-2969
Mailing Address - Fax:310-514-2995
Practice Address - Street 1:2003 CADDINGTON DR
Practice Address - Street 2:
Practice Address - City:RANCHO PALOS VERDES
Practice Address - State:CA
Practice Address - Zip Code:90275-2012
Practice Address - Country:US
Practice Address - Phone:310-514-2969
Practice Address - Fax:310-514-2995
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-02
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA19007207R00000X
CAC37718207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine