Provider Demographics
NPI:1083705289
Name:PEREZ, GODOFREDO BAUTISTA (MD)
Entity Type:Individual
Prefix:
First Name:GODOFREDO
Middle Name:BAUTISTA
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 1:134 S. PITTSBURGH ST
Mailing Address - Street 2:
Mailing Address - City:CONNELLSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15425
Mailing Address - Country:US
Mailing Address - Phone:724-628-0310
Mailing Address - Fax:
Practice Address - Street 1:134 S. PITTSBURGH ST
Practice Address - Street 2:
Practice Address - City:CONNELLSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15425
Practice Address - Country:US
Practice Address - Phone:724-628-0310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD032299-L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PE35356Medicare UPIN