Provider Demographics
NPI:1033183553
Name:PERALTA, MAYLENE I (MD)
Entity Type:Individual
Prefix:
First Name:MAYLENE
Middle Name:I
Last Name:PERALTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2510 AIRPARK DR STE 104
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-2461
Practice Address - Country:US
Practice Address - Phone:530-242-3570
Practice Address - Fax:530-242-3572
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC159045207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEH84367Medicare UPIN
MEOX1391Medicare PIN
MEMM994202Medicare PIN
MEMM994201Medicare PIN