Provider Demographics
NPI:1760445878
Name:PEREZ, JUAN MANUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:MANUEL
Last Name:PEREZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JUAN
Other - Middle Name:MANUEL
Other - Last Name:PEREZ MENDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:24445 NORTHWESTERN HWY
Mailing Address - Street 2:SUITE 206
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-6501
Mailing Address - Country:US
Mailing Address - Phone:248-799-0086
Mailing Address - Fax:248-350-1178
Practice Address - Street 1:24445 NORTHWESTERN HWY
Practice Address - Street 2:SUITE 206
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-6501
Practice Address - Country:US
Practice Address - Phone:248-799-0086
Practice Address - Fax:248-350-1178
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4696207V00000X
MI5315028244207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRC 78161Medicare UPIN
PR9-6598Medicare ID - Type Unspecified