Basic Information
| Provider Information | |||||||||
| NPI: | 1710013990 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PEAN | ||||||||
| FirstName: | PIERRE | ||||||||
| MiddleName: | ETIENNE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4740 N STATE ROAD 7 | ||||||||
| Address2: | |||||||||
| City: | LAUDERDALE LAKES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333195839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544864005 | ||||||||
| FaxNumber: | 9544973857 | ||||||||
| Practice Location | |||||||||
| Address1: | 1957 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | HOLLYWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330205021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549272393 | ||||||||
| FaxNumber: | 9544973857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2007 | ||||||||
| LastUpdateDate: | 11/16/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | ME0062634 | FL | N | Other Service Providers | Specialist | 2084P0800X | ME62364 | FL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 371158700 | 05 | FL | MEDICAID |