Provider Demographics
NPI:1083814883
Name:CHRISTOPHER R DPERSIO DPM PROF LLC
Entity Type:Organization
Organization Name:CHRISTOPHER R DPERSIO DPM PROF LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:DIPERSIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-584-3338
Mailing Address - Street 1:5 STADIUM PL
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-1129
Mailing Address - Country:US
Mailing Address - Phone:719-584-3338
Mailing Address - Fax:719-584-3337
Practice Address - Street 1:5 STADIUM PL
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-1129
Practice Address - Country:US
Practice Address - Phone:719-584-3338
Practice Address - Fax:719-584-3337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO531261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO39577376Medicaid
COU80375Medicare UPIN
CO39577376Medicaid