Healthcare Provider Details

I. General information

NPI: 1881996163
Provider Name (Legal Business Name): JOHN CARL PERALTA PINEDA DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2010
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 DOTY RD
HASKELL NJ
07420-3713
US

IV. Provider business mailing address

77 DOTY RD
HASKELL NJ
07420
US

V. Phone/Fax

Practice location:
  • Phone: 917-618-9881
  • Fax:
Mailing address:
  • Phone: 917-618-9881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number029628
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA01347600
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier40QA01347600
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerPT LICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: