Provider Demographics
NPI:1740303171
Name:PERUSEK, MARIE CECILIA (MD)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:CECILIA
Last Name:PERUSEK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8310 TIMBER GLEN ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78250-4434
Mailing Address - Country:US
Mailing Address - Phone:210-647-3272
Mailing Address - Fax:210-647-1376
Practice Address - Street 1:88 BRIGGS AVE., SOUTHWEST DIAGNOSTIC CENTER
Practice Address - Street 2:SUITE 110
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78224-4000
Practice Address - Country:US
Practice Address - Phone:210-921-0902
Practice Address - Fax:210-923-8220
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF99432085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC20437Medicare UPIN