Provider Demographics
NPI:1306875455
Name:RONALD W PELTON MD PHD PC
Entity type:Organization
Organization Name:RONALD W PELTON MD PHD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROSA
Authorized Official - Middle Name:M
Authorized Official - Last Name:TELLEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-329-0040
Mailing Address - Street 1:2770 N UNION BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-1120
Mailing Address - Country:US
Mailing Address - Phone:719-329-0040
Mailing Address - Fax:719-329-0080
Practice Address - Street 1:2770 N UNION BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-1120
Practice Address - Country:US
Practice Address - Phone:719-329-0040
Practice Address - Fax:719-329-0080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO97632082Medicaid
CO70722382Medicaid
CO97632082Medicaid
COC801995Medicare PIN