Provider Demographics
NPI:1619086105
Name:PERRY, JEANETTE (MD)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:
Last Name:PERRY
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 1:400 CANAL ST
Mailing Address - Street 2:STE A
Mailing Address - City:KING CITY
Mailing Address - State:CA
Mailing Address - Zip Code:93930-3461
Mailing Address - Country:US
Mailing Address - Phone:831-385-1280
Mailing Address - Fax:831-385-1285
Practice Address - Street 1:400 CANAL ST
Practice Address - Street 2:SUITE A
Practice Address - City:KING CITY
Practice Address - State:CA
Practice Address - Zip Code:93930-3461
Practice Address - Country:US
Practice Address - Phone:831-385-1280
Practice Address - Fax:831-385-1285
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG86421207Q00000X
NY180215207Q00000X
FLME83263207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYE94506Medicare UPIN