Provider Demographics
NPI:1548220429
Name:PELSANG, RETTA E (MD)
Entity Type:Individual
Prefix:
First Name:RETTA
Middle Name:E
Last Name:PELSANG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1970 E 53RD ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-2710
Mailing Address - Country:US
Mailing Address - Phone:563-359-3949
Mailing Address - Fax:
Practice Address - Street 1:1970 E 53RD ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-2710
Practice Address - Country:US
Practice Address - Phone:563-359-3949
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA280172085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
02954OtherBCBS IA RGPCSC
44976OtherBCBS IA RGIC LLC
IA1084871Medicaid
IA4084871Medicaid
F25625Medicare UPIN
02954Medicare ID - Type UnspecifiedRGPCSC
IA4084871Medicaid