Provider Demographics
NPI:1578658993
Name:PEREZ, PABLO ERMELO G (MD)
Entity Type:Individual
Prefix:
First Name:PABLO ERMELO
Middle Name:G
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 1:1425 N RANDALL RD
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-2300
Mailing Address - Country:US
Mailing Address - Phone:224-783-3450
Mailing Address - Fax:224-783-1124
Practice Address - Street 1:1425 N RANDALL RD
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-2300
Practice Address - Country:US
Practice Address - Phone:224-783-3450
Practice Address - Fax:224-783-1124
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22369207Q00000X
WI405242083P0011X
IL036-0962782083P0011X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036096278OtherLICENSE
SC223699Medicaid
SC1127Medicare PIN
IL036096278OtherLICENSE
SC223699Medicaid
SC1124Medicare PIN