Provider Demographics
NPI:1255639522
Name:MARK PEREZ , M.D.
Entity type:Organization
Organization Name:MARK PEREZ , M.D.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:E
Authorized Official - Last Name:BAEZ
Authorized Official - Suffix:
Authorized Official - Credentials:RND DPM LAC
Authorized Official - Phone:310-547-2197
Mailing Address - Street 1:1366 W. 7TH ST
Mailing Address - Street 2:SUITE 4-B
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3500
Mailing Address - Country:US
Mailing Address - Phone:310-547-2197
Mailing Address - Fax:
Practice Address - Street 1:1366 W 7TH ST
Practice Address - Street 2:SUITE 4-B
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3500
Practice Address - Country:US
Practice Address - Phone:310-547-2197
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAN PEDRO HEALING ARTS MEDICAL CLINIC INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-03-10
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG67514208D00000X
CAPA21347363A00000X
CAG067514261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG67514OtherMEDICAL BOARD