Provider Demographics
NPI:1366002461
Name:PEREZ, DANIEL SPENCER (OD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:SPENCER
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 1:9714 W 125TH AVE
Mailing Address - Street 2:
Mailing Address - City:CEDAR LAKE
Mailing Address - State:IN
Mailing Address - Zip Code:46303-9259
Mailing Address - Country:US
Mailing Address - Phone:708-439-9447
Mailing Address - Fax:
Practice Address - Street 1:833 N CASS ST
Practice Address - Street 2:
Practice Address - City:WABASH
Practice Address - State:IN
Practice Address - Zip Code:46992-1613
Practice Address - Country:US
Practice Address - Phone:260-563-3672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-19
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH006791152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist