Provider Demographics
NPI:1619617404
Name:PERALTA-FOGLE, AUSTIN REID (MD)
Entity Type:Individual
Prefix:DR
First Name:AUSTIN
Middle Name:REID
Last Name:PERALTA-FOGLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:AUSTIN
Other - Middle Name:REID
Other - Last Name:FOGLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1400 N IH 35 STE 2.230
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78701-1926
Mailing Address - Country:US
Mailing Address - Phone:512-324-8235
Mailing Address - Fax:
Practice Address - Street 1:1501 RED RIVER ST FL 2
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78712-1845
Practice Address - Country:US
Practice Address - Phone:512-495-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-30
Last Update Date:2023-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10082772208100000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation