Provider Demographics
NPI:1437582558
Name:PEREZ GOMEZ, JUAN SALVADOR (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:SALVADOR
Last Name:PEREZ GOMEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 LAKE ELLENOR DR STE 700
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32809-4643
Mailing Address - Country:US
Mailing Address - Phone:407-352-2542
Mailing Address - Fax:407-352-2547
Practice Address - Street 1:5900 LAKE ELLENOR DR STE 700
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-4643
Practice Address - Country:US
Practice Address - Phone:407-352-2542
Practice Address - Fax:407-352-2547
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-13
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ52679207R00000X
FLME149496208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ194403Medicaid