Provider Demographics
NPI:1750580452
Name:PEREZ, IVAN C (MD)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:C
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 1:709 MCFARLAND ST
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37814-3977
Mailing Address - Country:US
Mailing Address - Phone:423-587-2596
Mailing Address - Fax:423-585-0223
Practice Address - Street 1:709 MCFARLAND ST
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37814-3977
Practice Address - Country:US
Practice Address - Phone:423-587-2596
Practice Address - Fax:423-585-0223
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD00000183472084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3030960Medicaid
TN30309601Medicare PIN
TNB59025Medicare UPIN