Provider Demographics
NPI:1073578647
Name:PEREZ, ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
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 1:20 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601-3452
Mailing Address - Country:US
Mailing Address - Phone:304-831-1630
Mailing Address - Fax:304-831-1634
Practice Address - Street 1:20 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-3452
Practice Address - Country:US
Practice Address - Phone:304-831-1630
Practice Address - Fax:304-831-1634
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV20903207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3003748000Medicaid
WVPE7335731Medicare ID - Type Unspecified
WV3003748000Medicaid