Provider Demographics
NPI:1861790826
Name:PERAGALLO, JASON (MD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:PERAGALLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1365B CLIFTON RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30322-1013
Mailing Address - Country:US
Mailing Address - Phone:404-778-5360
Mailing Address - Fax:
Practice Address - Street 1:1365B CLIFTON RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-1013
Practice Address - Country:US
Practice Address - Phone:404-778-5360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-28
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA116847207W00000X
GA67588207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0A1168470Medicaid
CA0A1168470Medicaid