Provider Demographics
NPI:1760596456
Name:PEREZ, LUIS (OD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:
Last Name:PEREZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3323 S LOOP 256
Mailing Address - Street 2:
Mailing Address - City:PALESTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75801-6977
Mailing Address - Country:US
Mailing Address - Phone:903-723-1010
Mailing Address - Fax:903-723-0314
Practice Address - Street 1:1200 W MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:GUN BARREL CITY
Practice Address - State:TX
Practice Address - Zip Code:75156-5320
Practice Address - Country:US
Practice Address - Phone:903-880-9900
Practice Address - Fax:903-880-9902
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6799T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX178298901Medicaid
TX178298901Medicaid
8G0834Medicare ID - Type Unspecified