Provider Demographics
NPI:1598201410
Name:PERALTA, ALBERT (OD)
Entity Type:Individual
Prefix:
First Name:ALBERT
Middle Name:
Last Name:PERALTA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30-38 70TH STREET APT #3
Mailing Address - Street 2:
Mailing Address - City:EAST ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11370
Mailing Address - Country:US
Mailing Address - Phone:347-924-5566
Mailing Address - Fax:
Practice Address - Street 1:30-38 70TH STREET APT #3
Practice Address - Street 2:
Practice Address - City:EAST ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11370
Practice Address - Country:US
Practice Address - Phone:347-924-5566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-17
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV008648152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist