Healthcare Provider Details

I. General information

NPI: 1467448688
Provider Name (Legal Business Name): OLE ANTHONY PELOSO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 ENCINO PL NE STE C12
ALBUQUERQUE NM
87102-2612
US

IV. Provider business mailing address

1600 SIGMA CHI RD NE
ALBUQUERQUE NM
87106-4550
US

V. Phone/Fax

Practice location:
  • Phone: 505-247-4849
  • Fax: 505-247-4850
Mailing address:
  • Phone: 505-242-5504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number6965
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: