Provider Demographics
NPI:1649786443
Name:PEREZ, MAGDA I
Entity type:Individual
Prefix:
First Name:MAGDA
Middle Name:I
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 1:5219 MYSTIC POINT CT
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32812-5340
Mailing Address - Country:US
Mailing Address - Phone:786-510-1797
Mailing Address - Fax:
Practice Address - Street 1:5219 MYSTIC POINT CT
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32812-5340
Practice Address - Country:US
Practice Address - Phone:786-510-1797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-17
Last Update Date:2017-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLP620-540-66-758-0171R00000X
FLP620-549-66-758-0172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No171R00000XOther Service ProvidersInterpreter