Provider Demographics
NPI:1679214282
Name:PEREZ, CARLOS J (MD PHD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:J
Last Name:PEREZ
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:CARLOS
Other - Middle Name:J
Other - Last Name:PEREZ KERKVLIET
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD, PHD
Mailing Address - Street 1:1025 WALNUT ST STE 1100
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5001
Mailing Address - Country:US
Mailing Address - Phone:215-955-1419
Mailing Address - Fax:
Practice Address - Street 1:1025 WALNUT ST STE 1100
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5001
Practice Address - Country:US
Practice Address - Phone:215-955-1416
Practice Address - Fax:215-955-1884
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-06
Last Update Date:2022-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT226833390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program