1962767665 NPI number — DR. CHARLES WILLIAM PELTON O.D.

Table of content: DR. CHARLES WILLIAM PELTON O.D. (NPI 1962767665)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962767665 NPI number — DR. CHARLES WILLIAM PELTON O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PELTON
Provider First Name:
CHARLES
Provider Middle Name:
WILLIAM
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962767665
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
777 S NEW BALLAS RD
Provider Second Line Business Mailing Address:
SUITE 218E
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63141-8705
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-743-0400
Provider Business Mailing Address Fax Number:
314-743-0403

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
777 S NEW BALLAS RD
Provider Second Line Business Practice Location Address:
SUITE 218E
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63141-8705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-743-0400
Provider Business Practice Location Address Fax Number:
314-743-0403
Provider Enumeration Date:
07/09/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2012017231 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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