Provider Demographics
NPI:1740719814
Name:PERALTA, JERRICSON BARLIS (IDC)
Entity type:Individual
Prefix:
First Name:JERRICSON
Middle Name:BARLIS
Last Name:PERALTA
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6850 MISSION GORGE RD APT 1248
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-2478
Mailing Address - Country:US
Mailing Address - Phone:818-263-5345
Mailing Address - Fax:
Practice Address - Street 1:402 GOODRICH AVENUE
Practice Address - Street 2:
Practice Address - City:KITTERY
Practice Address - State:ME
Practice Address - Zip Code:03904
Practice Address - Country:US
Practice Address - Phone:207-438-1781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-12
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman