Provider Demographics
NPI:1811211683
Name:PEREZ, JUAN CARLOS (MA)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLOS
Last Name:PEREZ
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6916 NW 72ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33166-3036
Mailing Address - Country:US
Mailing Address - Phone:305-889-0188
Mailing Address - Fax:
Practice Address - Street 1:6916 NW 72ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33166-3036
Practice Address - Country:US
Practice Address - Phone:305-889-0188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-22
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHHC 8276261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA33029OtherLMT