Provider Demographics
NPI:1649312794
Name:PEREZ, EDWIN
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:
Last Name:PEREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:FANNE
Other - Middle Name:
Other - Last Name:GOODMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:R PH PHARM D
Mailing Address - Street 1:629 W 185TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-3102
Mailing Address - Country:US
Mailing Address - Phone:212-927-0999
Mailing Address - Fax:212-795-0470
Practice Address - Street 1:629 W 185TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-3102
Practice Address - Country:US
Practice Address - Phone:212-927-0999
Practice Address - Fax:212-795-0470
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027346183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02682915Medicaid