Provider Demographics
NPI:1144496068
Name:MARIO R PEREZ MD PA
Entity type:Organization
Organization Name:MARIO R PEREZ MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYCIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:R
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-914-3310
Mailing Address - Street 1:2075 MAIN ST
Mailing Address - Street 2:SUITE#1A
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34237-6057
Mailing Address - Country:US
Mailing Address - Phone:941-914-3310
Mailing Address - Fax:941-316-0185
Practice Address - Street 1:2075 MAIN ST
Practice Address - Street 2:SUITE#1A
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34237-6057
Practice Address - Country:US
Practice Address - Phone:941-914-3310
Practice Address - Fax:941-316-0185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-30
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME72969207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL277533600Medicaid
FL47211XMedicare PIN