Provider Demographics
NPI:1003081076
Name:PEREZ, RAUL ILUMINADO (MD)
Entity Type:Individual
Prefix:DR
First Name:RAUL
Middle Name:ILUMINADO
Last Name:PEREZ
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 1:605 S BROAD ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07202-2601
Mailing Address - Country:US
Mailing Address - Phone:908-659-0075
Mailing Address - Fax:908-469-4300
Practice Address - Street 1:605 S BROAD ST UNIT B
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07202-2601
Practice Address - Country:US
Practice Address - Phone:908-659-0075
Practice Address - Fax:908-469-4300
Is Sole Proprietor?:No
Enumeration Date:2008-04-29
Last Update Date:2011-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR16896207Q00000X
NJ25MA08784100207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0253651Medicaid