Provider Demographics
NPI:1598784332
Name:DE LARA, PEGGY L (AP, OMD)
Entity Type:Individual
Prefix:DR
First Name:PEGGY
Middle Name:L
Last Name:DE LARA
Suffix:
Gender:F
Credentials:AP, OMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10493
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33733-0493
Mailing Address - Country:US
Mailing Address - Phone:727-385-7528
Mailing Address - Fax:727-321-1178
Practice Address - Street 1:2555 2ND AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-8705
Practice Address - Country:US
Practice Address - Phone:727-385-7528
Practice Address - Fax:727-321-1178
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP 1751171100000X
FLPTA2040225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106898OtherMEDICARE ID