Provider Demographics
NPI:1568512598
Name:PERALTA, LAURA JEAN (DO)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:JEAN
Last Name:PERALTA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 WESTON RD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326-1912
Mailing Address - Country:US
Mailing Address - Phone:954-384-1800
Mailing Address - Fax:954-384-1802
Practice Address - Street 1:1040 WESTON RD
Practice Address - Street 2:SUITE 215
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33326-1912
Practice Address - Country:US
Practice Address - Phone:954-384-1800
Practice Address - Fax:954-384-1802
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 05699207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0659547OtherAETNA
FL209772OtherAVMED
049749OtherAOA
FL31129OtherSOUTHCARE PPO
FL1739248002OtherCIGNA
FL80211OtherBCBS
FL11096030OtherMULTIPLAN
FL80211Medicare ID - Type Unspecified
FL0659547OtherAETNA