Provider Demographics
NPI:1235146408
Name:PERLA, TODD A (MD)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:A
Last Name:PERLA
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 1:254 NW LAKE VALLEY TER
Mailing Address - Street 2:254 NW LAKE VALLEY TERRACE
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-8523
Mailing Address - Country:US
Mailing Address - Phone:386-754-9515
Mailing Address - Fax:352-265-0627
Practice Address - Street 1:194 SW WALL TERRACE
Practice Address - Street 2:ORIGINS FAMILY MEDICINE AND WEIGHT LOSS
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025
Practice Address - Country:US
Practice Address - Phone:386-719-9227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME65271207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL272819200Medicaid
FL272819200Medicaid
FLU5174VMedicare PIN
FLU5174CMedicare PIN