Provider Demographics
NPI:1255314654
Name:PELTON, EDWARD A (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:A
Last Name:PELTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 CENTENNIAL DR
Mailing Address - Street 2:PO BOX 431
Mailing Address - City:CHADRON
Mailing Address - State:NE
Mailing Address - Zip Code:69337-9400
Mailing Address - Country:US
Mailing Address - Phone:308-432-4441
Mailing Address - Fax:308-432-2130
Practice Address - Street 1:825 CENTENNIAL DR
Practice Address - Street 2:
Practice Address - City:CHADRON
Practice Address - State:NE
Practice Address - Zip Code:69337-9400
Practice Address - Country:US
Practice Address - Phone:308-432-4441
Practice Address - Fax:308-432-2130
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE18841207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE00081OtherBLUE SHIELD PROVIDER NUMB
NE18841OtherSTATE LICENSE NUMBER
NE00081OtherBLUE SHIELD PROVIDER NUMB
NE264401Medicare ID - Type UnspecifiedPERFORMING PROVIDER NUMBE
NE080059554Medicare ID - Type UnspecifiedRAILROAD MEDICARE NUMBER