Provider Demographics
NPI:1407948680
Name:PEREZ, NELLY MARIE (MD)
Entity Type:Individual
Prefix:
First Name:NELLY
Middle Name:MARIE
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 1:3501 HEALTH CENTER BLVD
Mailing Address - Street 2:#2160
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-8127
Mailing Address - Country:US
Mailing Address - Phone:239-948-4470
Mailing Address - Fax:239-948-0933
Practice Address - Street 1:3501 HEALTH CENTER BLVD
Practice Address - Street 2:#2160
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-8127
Practice Address - Country:US
Practice Address - Phone:239-948-4470
Practice Address - Fax:239-948-0933
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME71420207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL32604XMedicare PIN
FLG38952Medicare UPIN