Basic Information
Provider Information | |||||||||
NPI: | 1518966902 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PUGH | ||||||||
FirstName: | PEGGY | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | DEPT LA 21555 | ||||||||
Address2: |   | ||||||||
City: | PASADENA | ||||||||
State: | CA | ||||||||
PostalCode: | 911851555 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9492638620 | ||||||||
FaxNumber: | 8004097005 | ||||||||
Practice Location | |||||||||
Address1: | ONE HOAG DRIVE | ||||||||
Address2: |   | ||||||||
City: | NEWPORT BEACH | ||||||||
State: | CA | ||||||||
PostalCode: | 926634162 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9496453534 | ||||||||
FaxNumber: | 8004097005 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/18/2005 | ||||||||
LastUpdateDate: | 06/13/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | G57720 | CA | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 1518966902 | 05 | CA |   | MEDICAID | 00G577200 | 01 |   | BLUE SHIELD OF CA | OTHER | 00G577200Q92 | 01 |   | CALOPTIMA | OTHER | 300123286 | 01 |   | RAILROAD MEDICARE | OTHER | 00G577200 | 05 | CA |   | MEDICAID |