Provider Demographics
NPI:1841530649
Name:PEREZ, MARCO ANTONIO (MD)
Entity type:Individual
Prefix:DR
First Name:MARCO
Middle Name:ANTONIO
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 1:11001 62ND DR APT 11C
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-1283
Mailing Address - Country:US
Mailing Address - Phone:917-407-1013
Mailing Address - Fax:
Practice Address - Street 1:636 DEL PRADO BLVD S
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-2668
Practice Address - Country:US
Practice Address - Phone:239-424-3123
Practice Address - Fax:239-424-4140
Is Sole Proprietor?:No
Enumeration Date:2013-02-15
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2016-0243207Q00000X, 208M00000X
FLME129797208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100463700Medicaid