Provider Demographics
NPI:1578762191
Name:PERALTA-LEE, DIHLOREN ANTONIA (MD)
Entity Type:Individual
Prefix:
First Name:DIHLOREN
Middle Name:ANTONIA
Last Name:PERALTA-LEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DIHLOREN
Other - Middle Name:ANTONIA
Other - Last Name:PERALTA-LEE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 110820
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34108-0114
Mailing Address - Country:US
Mailing Address - Phone:239-431-6464
Mailing Address - Fax:
Practice Address - Street 1:4513 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34119-9033
Practice Address - Country:US
Practice Address - Phone:239-431-6464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-13
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME102170207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AP626ZMedicare PIN