Provider Demographics
NPI:1396721544
Name:PETERSON, ARLIN RAY (DPM)
Entity type:Individual
Prefix:DR
First Name:ARLIN
Middle Name:RAY
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 COLORADO AVE
Mailing Address - Street 2:STE D
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-2008
Mailing Address - Country:US
Mailing Address - Phone:719-544-5958
Mailing Address - Fax:719-544-5991
Practice Address - Street 1:509 COLORADO AVE
Practice Address - Street 2:STE D
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-2008
Practice Address - Country:US
Practice Address - Phone:719-544-5958
Practice Address - Fax:719-544-5991
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-20
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO648213E00000X
UT3476040501213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00250683OtherRAILROAD
CO19907541Medicaid
V00768Medicare UPIN
CO5366560001Medicare NSC
COC801690Medicare PIN