Provider Demographics
NPI:1164545992
Name:PEREZ, RAPHAEL E (OD)
Entity Type:Individual
Prefix:DR
First Name:RAPHAEL
Middle Name:E
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 1:524 FERNWOOD RD
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33149-1842
Mailing Address - Country:US
Mailing Address - Phone:786-853-1079
Mailing Address - Fax:305-860-3088
Practice Address - Street 1:1120 SW 8TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33130-3604
Practice Address - Country:US
Practice Address - Phone:786-853-1079
Practice Address - Fax:305-860-3088
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-08
Last Update Date:2017-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3418152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL257423300Medicaid
FL257423301Medicaid
FL20899AMedicare PIN
FL20899Medicare ID - Type Unspecified
FL257423300Medicaid