Provider Demographics
NPI:1457501686
Name:JUAN J PEREZ RUIZ M.D. A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:JUAN J PEREZ RUIZ M.D. A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:JOSE
Authorized Official - Last Name:PEREZ RUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-289-8717
Mailing Address - Street 1:461 HEYMANN BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-2616
Mailing Address - Country:US
Mailing Address - Phone:337-289-8717
Mailing Address - Fax:337-289-8718
Practice Address - Street 1:461 HEYMANN BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2616
Practice Address - Country:US
Practice Address - Phone:337-289-8717
Practice Address - Fax:337-289-8718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-24
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA022070261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
1821106261OtherNPI INDIVIDUAL
LA1492558Medicaid
G46168Medicare PIN
5Y367Medicare PIN