Provider Demographics
NPI:1346237534
Name:PERALTA, ENRIQUE
Entity Type:Individual
Prefix:DR
First Name:ENRIQUE
Middle Name:
Last Name:PERALTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11710 OLD BALLAS RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7076
Mailing Address - Country:US
Mailing Address - Phone:314-569-2020
Mailing Address - Fax:314-569-1596
Practice Address - Street 1:11710 OLD BALLAS RD
Practice Address - Street 2:SUITE 102
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7076
Practice Address - Country:US
Practice Address - Phone:314-569-2020
Practice Address - Fax:314-569-1596
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004012770207W00000X
IL036-112111207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209310200Medicaid
IL036112111Medicaid
MO209310200Medicaid
ILIL4498002Medicare PIN
IL790860Medicare PIN
ILR01426Medicare PIN
MO922372708Medicare PIN