Provider Demographics
NPI:1205916186
Name:PERALTA-KTTENGEL, IVANIA (MD)
Entity type:Individual
Prefix:
First Name:IVANIA
Middle Name:
Last Name:PERALTA-KTTENGEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 N OREGON ST
Mailing Address - Street 2:STE 700
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-3584
Mailing Address - Country:US
Mailing Address - Phone:915-544-2225
Mailing Address - Fax:915-577-9143
Practice Address - Street 1:1700 N OREGON ST
Practice Address - Street 2:STE 700
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-3584
Practice Address - Country:US
Practice Address - Phone:915-544-2225
Practice Address - Fax:915-577-9143
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM0862208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX177112301Medicaid
TX177112301Medicaid