Healthcare Provider Details

I. General information

NPI: 1992714158
Provider Name (Legal Business Name): GAUDENCIO PERALTA MARTINEZ JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 01/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 ORLEANS BLVD
COLDWATER MI
49036-1767
US

IV. Provider business mailing address

6821 JOSHUA TREE CT
PORTAGE MI
49024-1711
US

V. Phone/Fax

Practice location:
  • Phone: 517-278-2129
  • Fax: 517-279-8172
Mailing address:
  • Phone: 269-873-6019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4301401884
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: