Provider Demographics
NPI:1215918784
Name:PERALTA, ELIZABETH A (MD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:PERALTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3883 AIRWAY DRIVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-1671
Mailing Address - Country:US
Mailing Address - Phone:707-521-8900
Mailing Address - Fax:707-523-1309
Practice Address - Street 1:3883 AIRWAY DRIVE
Practice Address - Street 2:SUITE 201
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-1671
Practice Address - Country:US
Practice Address - Phone:707-521-8900
Practice Address - Fax:707-523-1309
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG83732208600000X
IL0361028222086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036102822Medicaid
IL036102822Medicaid
ILL78976Medicare ID - Type Unspecified