Healthcare Provider Details

I. General information

NPI: 1710094222
Provider Name (Legal Business Name): ADELQUI OSVALDO PERALTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 VFW PKWY
WEST ROXBURY MA
02132-4927
US

IV. Provider business mailing address

17 CLEARWATER RD
CHESTNUT HILL MA
02467-3706
US

V. Phone/Fax

Practice location:
  • Phone: 857-203-6860
  • Fax:
Mailing address:
  • Phone: 617-325-3167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number215690
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: