Provider Demographics
NPI:1093059412
Name:PEREZ, MARIO A
Entity Type:Individual
Prefix:MR
First Name:MARIO
Middle Name:A
Last Name:PEREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1222 10TH ST
Mailing Address - Street 2:SUITE 211
Mailing Address - City:WOODWARD
Mailing Address - State:OK
Mailing Address - Zip Code:73801-3156
Mailing Address - Country:US
Mailing Address - Phone:580-256-8615
Mailing Address - Fax:
Practice Address - Street 1:1222 10TH ST
Practice Address - Street 2:SUITE 211
Practice Address - City:WOODWARD
Practice Address - State:OK
Practice Address - Zip Code:73801-3156
Practice Address - Country:US
Practice Address - Phone:580-256-8615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health