Provider Demographics
NPI:1790043131
Name:PERRY, EDWARD T JR (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:T
Last Name:PERRY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:EDWARD
Other - Middle Name:THOMAS
Other - Last Name:PERRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:41870 GARSTIN DR
Mailing Address - Street 2:
Mailing Address - City:BIG BEAR LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:92315-2088
Mailing Address - Country:US
Mailing Address - Phone:909-866-6501
Mailing Address - Fax:
Practice Address - Street 1:41870 GARSTIN DR
Practice Address - Street 2:
Practice Address - City:BIG BEAR LAKE
Practice Address - State:CA
Practice Address - Zip Code:92315-2088
Practice Address - Country:US
Practice Address - Phone:909-866-6501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-23
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR5624207P00000X
AZ73232207P00000X
NMMD2017-0859207Q00000X
CAA127126207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine