Provider Demographics
NPI:1134184914
Name:PUEBLO RADIATION ONCOLOGY, P.C.
Entity type:Organization
Organization Name:PUEBLO RADIATION ONCOLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:STAGEBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-560-5482
Mailing Address - Street 1:1008 MINNEQUA AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-3733
Mailing Address - Country:US
Mailing Address - Phone:719-560-5482
Mailing Address - Fax:719-560-7217
Practice Address - Street 1:1008 MINNEQUA AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3733
Practice Address - Country:US
Practice Address - Phone:719-560-5482
Practice Address - Fax:719-560-7217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-17
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04006318Medicaid
COC317008Medicare Oscar/Certification