Provider Demographics
NPI:1710918222
Name:PERERA, MICHAEL G (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:G
Last Name:PERERA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 W DUARTE RD STE 702
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91007-9245
Mailing Address - Country:US
Mailing Address - Phone:626-445-1853
Mailing Address - Fax:626-445-8627
Practice Address - Street 1:612 W DUARTE RD
Practice Address - Street 2:STE 702
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91007-9245
Practice Address - Country:US
Practice Address - Phone:626-445-1853
Practice Address - Fax:626-445-8627
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA26963174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA24704Medicare UPIN