Provider Demographics
NPI:1184902991
Name:PEOTTER, JILL (DPM)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:PEOTTER
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:RIFLE
Mailing Address - State:CO
Mailing Address - Zip Code:81650-8510
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:501 AIRPORT RD
Practice Address - Street 2:GRAND RIVER HEALTH
Practice Address - City:RIFLE
Practice Address - State:CO
Practice Address - Zip Code:81650-8510
Practice Address - Country:US
Practice Address - Phone:970-625-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-27
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO742213ES0103X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO26405512Medicaid
CO379132YMJ3Medicare PIN