Provider Demographics
NPI:1710469721
Name:PEREZ, JESUS MOLINA
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:MOLINA
Last Name:PEREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8806 NW 109TH TER
Mailing Address - Street 2:
Mailing Address - City:HIALEAH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33018-4550
Mailing Address - Country:US
Mailing Address - Phone:786-302-7275
Mailing Address - Fax:
Practice Address - Street 1:8806 NW 109TH TER
Practice Address - Street 2:
Practice Address - City:HIALEAH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33018-4550
Practice Address - Country:US
Practice Address - Phone:786-302-7275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLM451421820930172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver