Provider Demographics
NPI:1962767665
Name:PELTON, CHARLES WILLIAM (OD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:WILLIAM
Last Name:PELTON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:777 S NEW BALLAS RD
Mailing Address - Street 2:SUITE 218E
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8705
Mailing Address - Country:US
Mailing Address - Phone:314-743-0400
Mailing Address - Fax:314-743-0403
Practice Address - Street 1:777 S NEW BALLAS RD
Practice Address - Street 2:SUITE 218E
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8705
Practice Address - Country:US
Practice Address - Phone:314-743-0400
Practice Address - Fax:314-743-0403
Is Sole Proprietor?:No
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012017231152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist