Provider Demographics
NPI:1003848268
Name:PEREZ, VANDELY (MD)
Entity Type:Individual
Prefix:
First Name:VANDELY
Middle Name:
Last Name:PEREZ
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 1:5378 W 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-2165
Mailing Address - Country:US
Mailing Address - Phone:305-820-4101
Mailing Address - Fax:305-820-2885
Practice Address - Street 1:5378 W 16TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-2165
Practice Address - Country:US
Practice Address - Phone:305-820-4101
Practice Address - Fax:305-820-2885
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85113208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLI21958Medicare UPIN
FL521113Medicare ID - Type UnspecifiedMEDICARE PROVIDER