Healthcare Provider Details

I. General information

NPI: 1669389987
Provider Name (Legal Business Name): FERNANDO EMMANUEL PERALTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1748 CROSBY AVE
BRONX NY
10461-4902
US

IV. Provider business mailing address

640 W 170TH ST APT 3D
NEW YORK NY
10032-3507
US

V. Phone/Fax

Practice location:
  • Phone: 718-792-2020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number011480
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: