1740668714 NPI number — MRS. IDA LISSETE PEREZ MSED SWD

Table of content: MRS. IDA LISSETE PEREZ MSED SWD (NPI 1740668714)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740668714 NPI number — MRS. IDA LISSETE PEREZ MSED SWD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEREZ
Provider First Name:
IDA
Provider Middle Name:
LISSETE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSED SWD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CREQUE
Provider Other First Name:
IDA
Provider Other Middle Name:
LISSETE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1740668714
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/06/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
34 STEPHENS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAPPAN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10983-2309
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
646-942-4941
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
34 STEPHENS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAPPAN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10983-2309
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
646-942-4941
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/11/2015

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: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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