Provider Demographics
NPI:1720152473
Name:PEREZ, MARK A (MD)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:A
Last Name:PEREZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4275 BURNHAM AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-5488
Mailing Address - Country:US
Mailing Address - Phone:702-384-7669
Mailing Address - Fax:702-385-7669
Practice Address - Street 1:4275 BURNHAM AVE. SUITE 210
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-5488
Practice Address - Country:US
Practice Address - Phone:702-384-7669
Practice Address - Fax:702-385-7669
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV14517207Q00000X
CAG067514207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G675140OtherBLUE SHIELD OF CA
CAG00675140Medicaid
F38101Medicare UPIN
CAG00675140Medicaid