Provider Demographics
NPI:1023057726
Name:PELLIGRA, JOHN (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:PELLIGRA
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:PO BOX 8000
Mailing Address - Street 2:DEPT 596
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14267-0002
Mailing Address - Country:US
Mailing Address - Phone:866-295-0041
Mailing Address - Fax:708-342-2517
Practice Address - Street 1:2164 HIGHWAY 35
Practice Address - Street 2:BLDG D-A
Practice Address - City:SEA GIRT
Practice Address - State:NJ
Practice Address - Zip Code:08750-1013
Practice Address - Country:US
Practice Address - Phone:732-974-0320
Practice Address - Fax:732-974-1283
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04651400207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1133209Medicaid
NJ450164Medicare PIN
NJ1133209Medicaid