Healthcare Provider Details

I. General information

NPI: 1821950353
Provider Name (Legal Business Name): SALIDA GENERAL SURGERY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2025
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 PINON DR
PONCHA SPRINGS CO
81242-5084
US

IV. Provider business mailing address

PO BOX 1295
PONCHA SPRINGS CO
81242-1003
US

V. Phone/Fax

Practice location:
  • Phone: 719-286-3170
  • Fax:
Mailing address:
  • Phone: 719-286-3170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. STEFAN IVERSON
Title or Position: GENERAL SURGEON
Credential: DO
Phone: 719-286-3170