Provider Demographics
NPI:1184733255
Name:PEGOLO, PETER (OD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:PEGOLO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 QUAKER LN S
Mailing Address - Street 2:SUITE B
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06110-1027
Mailing Address - Country:US
Mailing Address - Phone:860-236-1218
Mailing Address - Fax:860-231-9298
Practice Address - Street 1:612 QUAKER LN S
Practice Address - Street 2:SUITE B
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06110-1027
Practice Address - Country:US
Practice Address - Phone:860-236-1218
Practice Address - Fax:860-231-9298
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT02448152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2V5586OtherHEALTH NET
5094583OtherAETNA
002448OtherCONNECTICARE
090002448CT02OtherBLUE CROSS BLUE SHIELD
1749886OtherCIGNA
203912450OtherUNITED HEALTH CARE
203912450OtherVISION SERVICE PLAN
522108187187OtherTRICARE
203912450OtherUNITED HEALTH CARE
2V5586OtherHEALTH NET