Provider Demographics
NPI:1700087228
Name:KU, PEGGY (DO)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:
Last Name:KU
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 N MAIN ST
Mailing Address - Street 2:SUITE 242
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06117-2515
Mailing Address - Country:US
Mailing Address - Phone:860-231-1644
Mailing Address - Fax:860-231-8868
Practice Address - Street 1:345 N MAIN ST
Practice Address - Street 2:SUITE 242
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06117-2515
Practice Address - Country:US
Practice Address - Phone:860-231-1644
Practice Address - Fax:860-231-8868
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT045402207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT040045402CT01OtherANTHEM
CT045402OtherPHYSICIAN LICENSE
CT001454024Medicaid
CT045402OtherPHYSICIAN LICENSE