Provider Demographics
NPI:1144209404
Name:PELTON, RONALD W (MD, PHD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:W
Last Name:PELTON
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 E PIKES PEAK AVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-3674
Mailing Address - Country:US
Mailing Address - Phone:719-329-0040
Mailing Address - Fax:719-329-0080
Practice Address - Street 1:455 E PIKES PEAK AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-3648
Practice Address - Country:US
Practice Address - Phone:719-329-0040
Practice Address - Fax:719-329-0080
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO37739207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO70722382Medicaid
CO70722382Medicaid
COC801996Medicare PIN