Provider Demographics
NPI:1174822720
Name:PEREZ, MARCELLA DENISE (MD)
Entity Type:Individual
Prefix:
First Name:MARCELLA
Middle Name:DENISE
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 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:5109 NEW CUT RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40214-2745
Practice Address - Country:US
Practice Address - Phone:502-361-1197
Practice Address - Fax:502-361-0090
Is Sole Proprietor?:No
Enumeration Date:2011-03-22
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY46859208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY165148OtherSIHO
KY50075460OtherPASSPORT - NCMA OKOLONA
KY50083958OtherPASSPORT - NCMA IROQUOIS
KY000000885932OtherANTHEM-NCMA
KY7100318020Medicaid
KYK146630Medicare PIN