Basic Information
| Provider Information | |||||||||
| NPI: | 1568512598 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PERALTA | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1040 WESTON RD | ||||||||
| Address2: | SUITE 215 | ||||||||
| City: | WESTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333261912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543841800 | ||||||||
| FaxNumber: | 9543841802 | ||||||||
| Practice Location | |||||||||
| Address1: | 1040 WESTON RD | ||||||||
| Address2: | SUITE 215 | ||||||||
| City: | WESTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333261912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543841800 | ||||||||
| FaxNumber: | 9543841802 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 07/27/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS 05699 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0659547 | 01 | FL | AETNA | OTHER | 209772 | 01 | FL | AVMED | OTHER | 049749 | 01 | AOA | OTHER | 31129 | 01 | FL | SOUTHCARE PPO | OTHER | 1739248002 | 01 | FL | CIGNA | OTHER | 80211 | 01 | FL | BCBS | OTHER | 11096030 | 01 | FL | MULTIPLAN | OTHER |