Provider Demographics
NPI:1295933448
Name:PERALTA, SOTERO (MD)
Entity type:Individual
Prefix:DR
First Name:SOTERO
Middle Name:
Last Name:PERALTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3310 WATERMAN WAY
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-5250
Mailing Address - Country:US
Mailing Address - Phone:352-385-3022
Mailing Address - Fax:352-385-3023
Practice Address - Street 1:3310 WATERMAN WAY
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-5250
Practice Address - Country:US
Practice Address - Phone:352-385-3022
Practice Address - Fax:352-385-3023
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.0969642086S0129X
TXS35652086S0129X
FLME1383012086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH08LY79901OtherBCBS
TX405201101Medicaid