Provider Demographics
NPI:1942253273
Name:PEREZ SURGICAL MEDICAL GROUP
Entity Type:Organization
Organization Name:PEREZ SURGICAL MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-500-9973
Mailing Address - Street 1:1510 S CENTRAL AVE
Mailing Address - Street 2:#200
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2500
Mailing Address - Country:US
Mailing Address - Phone:818-500-9973
Mailing Address - Fax:818-500-1204
Practice Address - Street 1:1510 S CENTRAL AVE
Practice Address - Street 2:#200
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2500
Practice Address - Country:US
Practice Address - Phone:818-500-9973
Practice Address - Fax:818-500-1204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAN/A2085U0001X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Single Specialty
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW13949Medicare ID - Type UnspecifiedMEDICARE GROUP PROVIDER #