Provider Demographics
NPI:1013905744
Name:PEREZ, VICTORIA
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:PEREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4855 W HILLSBORO BLVD
Mailing Address - Street 2:SUITE B 2
Mailing Address - City:COCONUT CREEK
Mailing Address - State:FL
Mailing Address - Zip Code:33073-4356
Mailing Address - Country:US
Mailing Address - Phone:954-418-1683
Mailing Address - Fax:954-418-1698
Practice Address - Street 1:5355 LYONS RD
Practice Address - Street 2:
Practice Address - City:COCONUT CREEK
Practice Address - State:FL
Practice Address - Zip Code:33073-2825
Practice Address - Country:US
Practice Address - Phone:954-570-9595
Practice Address - Fax:954-354-8151
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102528363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292586900Medicaid
Q36395Medicare UPIN
FLU4246UMedicare PIN
FL292586900Medicaid
FLU4246WMedicare PIN