Provider Demographics
NPI:1730195751
Name:PERERA, TARIQUE (MD)
Entity type:Individual
Prefix:
First Name:TARIQUE
Middle Name:
Last Name:PERERA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 HOSPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-6021
Mailing Address - Country:US
Mailing Address - Phone:203-792-0400
Mailing Address - Fax:203-792-0404
Practice Address - Street 1:84 HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-6021
Practice Address - Country:US
Practice Address - Phone:203-792-0400
Practice Address - Fax:203-792-0404
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0392322084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT260004378Medicare PIN
CTI00703Medicare UPIN