Provider Demographics
NPI:1124027859
Name:PEREZ, ELBA ANTOINETTE (MD)
Entity Type:Individual
Prefix:DR
First Name:ELBA
Middle Name:ANTOINETTE
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:PO BOX 193868
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00919-3868
Mailing Address - Country:US
Mailing Address - Phone:787-748-7120
Mailing Address - Fax:787-748-7105
Practice Address - Street 1:EXPRESO TRUJILLO ALTO KM 4.4
Practice Address - Street 2:SAN MIGUEL MEDICAL - SUITE 204 PLAZA SAN MIGUEL
Practice Address - City:TRUJILLO ALTO
Practice Address - State:PR
Practice Address - Zip Code:00976
Practice Address - Country:US
Practice Address - Phone:787-748-7120
Practice Address - Fax:787-748-7105
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-15
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13348208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR84345OtherTRIPLE-S, INC
PR500350OtherMMM HEATHCARE
PR9760040OtherHUMANA HEALTH CARE
PR13348OtherSTATE LICENSE
PR500350OtherMMM HEATHCARE
PR84345OtherTRIPLE-S, INC
PR0084345Medicare ID - Type UnspecifiedPROVIDER