Healthcare Provider Details

I. General information

NPI: 1134184914
Provider Name (Legal Business Name): PUEBLO RADIATION ONCOLOGY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 07/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 MINNEQUA AVE
PUEBLO CO
81004-3733
US

IV. Provider business mailing address

1008 MINNEQUA AVE
PUEBLO CO
81004-3733
US

V. Phone/Fax

Practice location:
  • Phone: 719-560-5482
  • Fax: 719-560-7217
Mailing address:
  • Phone: 719-560-5482
  • Fax: 719-560-7217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN D STAGEBERG
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 719-560-5482