Provider Demographics
NPI:1467669325
Name:PEREZ, JORGE LAZARO
Entity Type:Individual
Prefix:MR
First Name:JORGE
Middle Name:LAZARO
Last Name:PEREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13055 SW 42ND ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-3406
Mailing Address - Country:US
Mailing Address - Phone:305-519-6268
Mailing Address - Fax:305-559-1633
Practice Address - Street 1:13055 SW 42ND ST
Practice Address - Street 2:SUITE 206
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-3406
Practice Address - Country:US
Practice Address - Phone:305-519-6268
Practice Address - Fax:305-559-1633
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRCVT23802471V0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471V0105XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular Sonography
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE1841Medicare ID - Type Unspecified