Provider Demographics
NPI:1477687960
Name:PEREZ, VICTORIANO (MD)
Entity Type:Individual
Prefix:
First Name:VICTORIANO
Middle Name:
Last Name:PEREZ
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 1:1730 EVERGREEN LN
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1104
Mailing Address - Country:US
Mailing Address - Phone:847-825-4285
Mailing Address - Fax:847-825-4285
Practice Address - Street 1:850 W IRVING PARK RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-3077
Practice Address - Country:US
Practice Address - Phone:773-975-3260
Practice Address - Fax:773-975-6869
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036065192207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL652760Medicare ID - Type Unspecified
ILD15934Medicare UPIN