Provider Demographics
NPI:1871672972
Name:PESHOCK, JAMES R (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:R
Last Name:PESHOCK
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:PO BOX 1588
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80306-1588
Mailing Address - Country:US
Mailing Address - Phone:303-442-5492
Mailing Address - Fax:303-447-3610
Practice Address - Street 1:2336 CANYON BLVD STE 100
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-5653
Practice Address - Country:US
Practice Address - Phone:303-442-5492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23310207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01233105Medicaid
CO01233105Medicaid
COD24255Medicare UPIN