Provider Demographics
NPI:1831356724
Name:VICIOSO PERALTA, LUIS EMILIO (MD)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:EMILIO
Last Name:VICIOSO 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 1:7261 SHERIDAN ST STE 100D
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33024-2708
Mailing Address - Country:US
Mailing Address - Phone:954-534-7696
Mailing Address - Fax:954-534-7731
Practice Address - Street 1:7261 SHERIDAN ST STE 100D
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33024
Practice Address - Country:US
Practice Address - Phone:954-534-7696
Practice Address - Fax:954-534-7731
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-19
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA239261207R00000X
FLME112745207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine