1124003546 NPI number — MR. ANTHONY TREVOR PERRIN DO, MBA

Table of content: IBIYE OWEI NWANZE MD (NPI 1336672468)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124003546 NPI number — MR. ANTHONY TREVOR PERRIN DO, MBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PERRIN
Provider First Name:
ANTHONY
Provider Middle Name:
TREVOR
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
DO, MBA
Provider Gender Code:
M

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:
1124003546
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/16/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 952816
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE MARY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32795-2816
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-716-5776
Provider Business Mailing Address Fax Number:
321-256-0667

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1236 ROYAL PALM BLVD
Provider Second Line Business Practice Location Address:
SUITE 108
Provider Business Practice Location Address City Name:
ROYAL PALM BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-774-8660
Provider Business Practice Location Address Fax Number:
561-774-8665
Provider Enumeration Date:
12/08/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  OS8957 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 267359200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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