Provider Demographics
NPI:1952314007
Name:PEREZ, MANUEL ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:ROBERT
Last Name:PEREZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:M.
Other - Middle Name:ROBERT
Other - Last Name:PEREZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1711 ASHLEY CIR
Mailing Address - Street 2:SUITE 7 AND 8
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-5801
Mailing Address - Country:US
Mailing Address - Phone:270-782-0405
Mailing Address - Fax:270-782-9683
Practice Address - Street 1:1711 ASHLEY CIR
Practice Address - Street 2:SUITE 7 AND 8
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-5801
Practice Address - Country:US
Practice Address - Phone:270-782-0405
Practice Address - Fax:270-782-9683
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY16554174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64165541Medicaid
KYD08100Medicare UPIN
KY64165541Medicaid