Provider Demographics
NPI:1548216443
Name:BERTOLDO, FRED JEFFREY (MD)
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:JEFFREY
Last Name:BERTOLDO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:F
Other - Middle Name:JEFFREY
Other - Last Name:BERTOLDO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 11512
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-0512
Mailing Address - Country:US
Mailing Address - Phone:719-542-2167
Mailing Address - Fax:719-542-0320
Practice Address - Street 1:1619 N GREENWOOD ST
Practice Address - Street 2:SUITE 103
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2644
Practice Address - Country:US
Practice Address - Phone:719-542-2167
Practice Address - Fax:719-542-0320
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO350942085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01350941Medicaid
COC455878Medicare PIN
COC75674Medicare PIN
CO01350941Medicaid
COC11758Medicare PIN