Provider Demographics
NPI:1265691109
Name:PELTZ, CARRIE MARIE (MD)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:MARIE
Last Name:PELTZ
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 1:1000 BOULDERS PKWY STE 102
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23225-5515
Mailing Address - Country:US
Mailing Address - Phone:804-320-4243
Mailing Address - Fax:804-622-0552
Practice Address - Street 1:1000 BOULDERS PKWY STE 102
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23225-5515
Practice Address - Country:US
Practice Address - Phone:804-320-4243
Practice Address - Fax:804-622-0552
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.093087207R00000X
VA0101246748207RP1001X, 207RC0200X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3023767Medicaid
OH3023767Medicaid