Provider Demographics
NPI:1467448688
Name:PELOSO, OLE ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:OLE
Middle Name:ANTHONY
Last Name:PELOSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1600 SIGMA CHI RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4550
Mailing Address - Country:US
Mailing Address - Phone:505-242-5504
Mailing Address - Fax:
Practice Address - Street 1:801 ENCINO PL NE
Practice Address - Street 2:STE C12
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2612
Practice Address - Country:US
Practice Address - Phone:505-247-4849
Practice Address - Fax:505-247-4850
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6965208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
23312OtherPHP
NM012133OtherBCBS
NM21337Medicaid
NM21337Medicaid