Provider Demographics
NPI:1376591966
Name:PEREZ, EVELINA VEGA (MSPT)
Entity Type:Individual
Prefix:
First Name:EVELINA
Middle Name:VEGA
Last Name:PEREZ
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 GARRISON BLVD
Mailing Address - Street 2:SUITE 190
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21216-2335
Mailing Address - Country:US
Mailing Address - Phone:410-566-2501
Mailing Address - Fax:410-566-3025
Practice Address - Street 1:2300 GARRISON BLVD
Practice Address - Street 2:SUITE 190
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21216-2335
Practice Address - Country:US
Practice Address - Phone:410-566-2501
Practice Address - Fax:410-566-3025
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD19529225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDE705OtherFEDERAL BLUECROSS/SHIELD
MDLV17OtherCAREFIRST BLUECROSS/SHIEL