Provider Demographics
NPI:1891189635
Name:PEREZ, JOSE ALBERTO
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:ALBERTO
Last Name:PEREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8811 34TH AVE APT 3C
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-3424
Mailing Address - Country:US
Mailing Address - Phone:347-355-1675
Mailing Address - Fax:
Practice Address - Street 1:8811 34TH AVE APT 3C
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-3424
Practice Address - Country:US
Practice Address - Phone:347-355-1675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-18
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYME50515PMedicaid