Provider Demographics
NPI:1184612467
Name:PEREZ, JOHNNY (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:JOHNNY
Middle Name:
Last Name:PEREZ
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 N ACADIA ROAD STE 406
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-4897
Mailing Address - Country:US
Mailing Address - Phone:985-446-2524
Mailing Address - Fax:
Practice Address - Street 1:604 N ACADIA ROAD STE 406
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-4897
Practice Address - Country:US
Practice Address - Phone:985-446-2524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2009-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15745R208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1465534Medicaid
LAG33787Medicare UPIN
LA1465534Medicaid