Provider Demographics
NPI:1184844771
Name:ELY D PELTA MD PA
Entity type:Organization
Organization Name:ELY D PELTA MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELY
Authorized Official - Middle Name:D
Authorized Official - Last Name:PELTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-345-8733
Mailing Address - Street 1:5551 N UNIVERSITY DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33067-4651
Mailing Address - Country:US
Mailing Address - Phone:954-345-8733
Mailing Address - Fax:954-345-8233
Practice Address - Street 1:5551 N UNIVERSITY DR
Practice Address - Street 2:SUITE 102
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33067-4651
Practice Address - Country:US
Practice Address - Phone:954-345-8733
Practice Address - Fax:954-345-8233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCM3126OtherMEDICARE RAILROAD
FLAC362Medicare PIN
FLCM3126OtherMEDICARE RAILROAD