Provider Demographics
NPI:1467411173
Name:PELLETIER, RENE (MD)
Entity Type:Individual
Prefix:
First Name:RENE
Middle Name:
Last Name:PELLETIER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1880 BIG LAKE DR
Mailing Address - Street 2:
Mailing Address - City:OSCEOLA
Mailing Address - State:WI
Mailing Address - Zip Code:54020-4724
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:153 CESAR CHAVEZ ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55107-2226
Practice Address - Country:US
Practice Address - Phone:651-222-1816
Practice Address - Fax:651-602-7517
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN17248207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP14144OtherHEALTH PARTNERS
MNNA9020010659OtherPREFERRED ONE
MN08-00400OtherMEDICA
MN101306OtherUCARE
MN27016PEOtherBCBS
MN27016PEOtherBCBS