Provider Demographics
NPI:1295995611
Name:ROBERT R PEREZ MD PC
Entity type:Organization
Organization Name:ROBERT R PEREZ MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MD OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:R
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD PC
Authorized Official - Phone:478-252-5259
Mailing Address - Street 1:PO BOX 760
Mailing Address - Street 2:51 NORTH MAIN STREET
Mailing Address - City:WASLEY
Mailing Address - State:GA
Mailing Address - Zip Code:30477-0760
Mailing Address - Country:US
Mailing Address - Phone:478-252-5259
Mailing Address - Fax:478-252-0413
Practice Address - Street 1:51 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:WASLEY
Practice Address - State:GA
Practice Address - Zip Code:30477-0760
Practice Address - Country:US
Practice Address - Phone:478-252-5259
Practice Address - Fax:478-252-0413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000042208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000137992AMedicaid
GA284266330AMedicare PIN
GAF31806Medicare UPIN