Provider Demographics
NPI:1164482246
Name:PEREZ, MICHAEL (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:PEREZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 PLEASANT AVE S
Mailing Address - Street 2:
Mailing Address - City:PARK RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56470-1417
Mailing Address - Country:US
Mailing Address - Phone:218-732-3389
Mailing Address - Fax:218-732-5994
Practice Address - Street 1:206 PLEASANT AVE S
Practice Address - Street 2:
Practice Address - City:PARK RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56470-1417
Practice Address - Country:US
Practice Address - Phone:218-732-3389
Practice Address - Fax:218-732-5994
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1717152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN704523900Medicaid
MN704523900Medicaid
MNT65982Medicare UPIN