Provider Demographics
NPI:1952558165
Name:PEREZ, RAFAEL A
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:A
Last Name:PEREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11776 STRATFORD HOUSE PL APT 1009
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-3384
Mailing Address - Country:US
Mailing Address - Phone:703-802-7096
Mailing Address - Fax:703-802-7113
Practice Address - Street 1:14225 NEWBROOK DRIVE
Practice Address - Street 2:QUEST DIAGNOSTICS NICHOLS INSTITUTE
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151
Practice Address - Country:US
Practice Address - Phone:703-802-7096
Practice Address - Fax:703-802-7113
Is Sole Proprietor?:No
Enumeration Date:2008-08-20
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101236693207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD61819Medicare UPIN