Provider Demographics
NPI:1124587225
Name:PEREZ AGUDELO, MARIA LUCIA (MD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:LUCIA
Last Name:PEREZ AGUDELO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LUCIA
Other - Middle Name:
Other - Last Name:AGUDDELO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3569 ROUND BARN CIR STE 200
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-5781
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3569 ROUND BARN CIR STE 200
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-5781
Practice Address - Country:US
Practice Address - Phone:707-583-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-18
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA181615207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE