Provider Demographics
NPI:1518964253
Name:PEREZ, STACY LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:LYNN
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 1:621 MEDICAL CARE DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5942
Mailing Address - Country:US
Mailing Address - Phone:813-657-3330
Mailing Address - Fax:813-657-3348
Practice Address - Street 1:621 MEDICAL CARE DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5942
Practice Address - Country:US
Practice Address - Phone:813-657-3330
Practice Address - Fax:813-657-3348
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME75014174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL62798OtherBC/BS
FLH74814Medicare UPIN
FL62798OtherBC/BS
FLK3956Medicare ID - Type UnspecifiedGROUP ID