Provider Demographics
NPI:1609472703
Name:PEREZ, OCTAVIO (SA-C)
Entity Type:Individual
Prefix:
First Name:OCTAVIO
Middle Name:
Last Name:PEREZ
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16130 SW 97TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33157-3358
Mailing Address - Country:US
Mailing Address - Phone:786-828-3207
Mailing Address - Fax:
Practice Address - Street 1:16130 SW 97TH CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33157-3358
Practice Address - Country:US
Practice Address - Phone:786-828-3207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-05
Last Update Date:2020-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20-453246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant