Provider Demographics
NPI:1558639922
Name:PELTAN OPTICAL
Entity Type:Organization
Organization Name:PELTAN OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:IVENS
Authorized Official - Last Name:PELTAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:6625-454-4600
Mailing Address - Street 1:425B N DAVIS AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-2351
Mailing Address - Country:US
Mailing Address - Phone:662-545-4600
Mailing Address - Fax:662-545-4595
Practice Address - Street 1:425B N DAVIS AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-2351
Practice Address - Country:US
Practice Address - Phone:662-545-4600
Practice Address - Fax:662-545-4595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-13
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS20927207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty