Provider Demographics
NPI:1316501000
Name:PELLETIER, IAN (DO)
Entity type:Individual
Prefix:DR
First Name:IAN
Middle Name:
Last Name:PELLETIER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 W MULBERRY STE A
Mailing Address - Street 2:
Mailing Address - City:PILOT KNOB
Mailing Address - State:MO
Mailing Address - Zip Code:63663-7883
Mailing Address - Country:US
Mailing Address - Phone:573-546-0602
Mailing Address - Fax:573-546-0624
Practice Address - Street 1:315 W MULBERRY STE A
Practice Address - Street 2:
Practice Address - City:PILOT KNOB
Practice Address - State:MO
Practice Address - Zip Code:63663-7883
Practice Address - Country:US
Practice Address - Phone:573-546-0602
Practice Address - Fax:573-546-0624
Is Sole Proprietor?:No
Enumeration Date:2019-04-28
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2022019197207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program