Provider Demographics
NPI:1174504815
Name:PEREZ, JOHN MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
Last Name:PEREZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1100 REID PKWY
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1157
Mailing Address - Country:US
Mailing Address - Phone:765-935-8802
Mailing Address - Fax:765-983-3219
Practice Address - Street 1:1050 REID PKWY
Practice Address - Street 2:SUITE 325
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1155
Practice Address - Country:US
Practice Address - Phone:765-962-8551
Practice Address - Fax:765-962-2591
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01024969A208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0616220Medicaid
IN000000705065OtherANTHEM
IN100324610Medicaid
IN000000705065OtherANTHEM
OH0616220Medicaid
OHH349860Medicare PIN