Provider Demographics
NPI:1629198007
Name:CELESTINO M. PEREZ MD SC
Entity Type:Organization
Organization Name:CELESTINO M. PEREZ MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CELESTINO
Authorized Official - Middle Name:M
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-284-2636
Mailing Address - Street 1:126 E PIER STREET
Mailing Address - Street 2:P O BOX 6
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074-0006
Mailing Address - Country:US
Mailing Address - Phone:262-284-2636
Mailing Address - Fax:262-284-2722
Practice Address - Street 1:126 E PIER STREET
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074-0006
Practice Address - Country:US
Practice Address - Phone:262-284-2636
Practice Address - Fax:262-284-2722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20479207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000046475Medicare ID - Type Unspecified