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General NPI Number Information
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NPI Number | 1578991089
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Entity Type | Organization
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Legal Business Name | PERALTA PRIMARY CARE P.C.
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Dates
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Enumeration Date | 10/18/2013
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Last Update Date | 10/18/2013
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Provider Practice Location Address
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Address Line | 4310 52ND ST DAHON WELLNESS CENTER
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City | WOODSIDE
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State | NY
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Zip | 11377-4542
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Country | US
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Telephone | 718-255-6229
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Fax | 718-255-1288
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Provider Business Mailing Address
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Address Line | 30 CRESCENT PL
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City | YONKERS
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State | NY
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Zip | 10704-2516
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Country | US
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Telephone | 914-803-1151
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Fax | 845-512-8628
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Authorized Official
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Title or Position | OWNER
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Name | DR. MARK FACTURA PERALTA
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Credential | M.D.
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Telephone | 646-675-4671
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 242019
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License Number State | NY
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