Provider Demographics
NPI:1568861995
Name:PERALTA, MODESTO JR (MD)
Entity Type:Individual
Prefix:DR
First Name:MODESTO
Middle Name:
Last Name:PERALTA
Suffix:JR
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 1:423 W FENWAY DR
Mailing Address - Street 2:
Mailing Address - City:HERNANDO
Mailing Address - State:FL
Mailing Address - Zip Code:34442-5144
Mailing Address - Country:US
Mailing Address - Phone:440-567-0113
Mailing Address - Fax:
Practice Address - Street 1:423 W FENWAY DR
Practice Address - Street 2:
Practice Address - City:HERNANDO
Practice Address - State:FL
Practice Address - Zip Code:34442-5144
Practice Address - Country:US
Practice Address - Phone:440-567-0113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.034631208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)