Healthcare Provider Details

I. General information

NPI: 1649610890
Provider Name (Legal Business Name): BRANNON PHILLIP PERALTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2013
Last Update Date: 05/26/2023
Certification Date: 05/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23625 HOLMAN HWY
MONTEREY CA
93940-5902
US

IV. Provider business mailing address

567 WARREN ST APT 503
BROOKLYN NY
11217
US

V. Phone/Fax

Practice location:
  • Phone: 831-625-5311
  • Fax:
Mailing address:
  • Phone: 408-431-7392
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberA151902
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number56517
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: