Provider Demographics
NPI:1932178308
Name:PEREZ, RUBEN EDGARDO (MD)
Entity Type:Individual
Prefix:
First Name:RUBEN
Middle Name:EDGARDO
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 1:350 1ST ST N
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-4113
Mailing Address - Country:US
Mailing Address - Phone:863-595-4130
Mailing Address - Fax:863-595-0459
Practice Address - Street 1:350 1ST ST N
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4113
Practice Address - Country:US
Practice Address - Phone:863-595-4130
Practice Address - Fax:863-595-0459
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME70231207R00000X
FLME0070231207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL250120100Medicaid
FL110169445OtherMEDICARE ID/ RRM PIN
FLG25476Medicare UPIN
FL28868ZMedicare PIN