Provider Demographics
NPI:1881755650
Name:PEREZ, EDWARD PENA (MD PHD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:PENA
Last Name:PEREZ
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4919 MEMORIAL HWY STE 150
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-7516
Mailing Address - Country:US
Mailing Address - Phone:813-333-1512
Mailing Address - Fax:813-333-1561
Practice Address - Street 1:1999 MEDICAL PKWY STE A
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-7579
Practice Address - Country:US
Practice Address - Phone:512-392-1411
Practice Address - Fax:512-392-1422
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL7107207N00000X, 207NS0135X, 207NS0135X
MA210522207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX469332ZH88Medicare PIN