Provider Demographics
NPI:1942218086
Name:PEREZ, PABLO E (MD)
Entity Type:Individual
Prefix:
First Name:PABLO
Middle Name:E
Last Name:PEREZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 W WAUGH ST
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720
Mailing Address - Country:US
Mailing Address - Phone:706-277-2321
Mailing Address - Fax:706-226-1492
Practice Address - Street 1:1102 W. WAUGH ST
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720
Practice Address - Country:US
Practice Address - Phone:706-277-2321
Practice Address - Fax:706-428-2812
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047502207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA201508121AMedicaid
GA201508121AMedicaid
GAH09926Medicare UPIN