Provider Demographics
NPI:1245451194
Name:PERALTA, MANUEL T JR (MD)
Entity type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:T
Last Name:PERALTA
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:2103 GRAVES MILL RD
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:VA
Mailing Address - Zip Code:24551-2675
Mailing Address - Country:US
Mailing Address - Phone:434-316-7199
Mailing Address - Fax:434-316-6185
Practice Address - Street 1:2103 GRAVES MILL RD
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:VA
Practice Address - Zip Code:24551-2675
Practice Address - Country:US
Practice Address - Phone:434-316-7199
Practice Address - Fax:434-316-6185
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101241169207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1245451194OtherSOUTHERN HEALTH
VA1245451194Medicaid
014695A65OtherMEDICARE RAIL ROAD
1245451194OtherTRICARE
302185OtherANTHEM
3700863OtherCIGNA
541901162OtherPCHP
014695A65Medicare PIN