Provider Demographics
NPI:1932201183
Name:PEGOUSKE, DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:PEGOUSKE
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 1:14801 FARMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154
Mailing Address - Country:US
Mailing Address - Phone:734-542-8100
Mailing Address - Fax:734-542-8168
Practice Address - Street 1:14801 FARMINGTON RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154
Practice Address - Country:US
Practice Address - Phone:734-542-8100
Practice Address - Fax:734-542-8168
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070087207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIC7845OtherM-CARE OF MICHIGAN
MI6180642OtherCIGNA
MA5479258OtherCNN FIRST HEALTH
MI133931OtherCARE CHOICES
MI6180642003OtherCHANDLER PHS
MIH36350OtherHAP INSURANCE
MI0708217311OtherBCBSM
MI12005406OtherMULTIPLAN
MI12005406OtherMULTIPLAN
MI6180642OtherCIGNA