1083962856 NPI number — MARK A PEREZ, M.D., LLC

Table of content: (NPI 1083962856)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083962856 NPI number — MARK A PEREZ, M.D., LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARK A PEREZ, M.D., LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083962856
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4275 BURNHAM AVE
Provider Second Line Business Mailing Address:
SUITE 235
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89119-5488
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-384-7669
Provider Business Mailing Address Fax Number:
702-385-7669

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4275 BURNHAM AVE
Provider Second Line Business Practice Location Address:
SUITE 235
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89119-5488
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-384-7669
Provider Business Practice Location Address Fax Number:
702-385-7669
Provider Enumeration Date:
08/27/2012

Additional Information

Authorized Official

Authorized Official Last Name:
PEREZ
Authorized Official First Name:
MARK
Authorized Official Middle Name:
A
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
702-384-7669

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  14517 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: G00675140 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 14517 . This is a "NEVADA LICENSE NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: G00675140 . This is a "MEDICARE ID" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: F38101 . This is a "MEDICARE UPIN" identifier . This identifiers is of the category "OTHER".




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