Provider Demographics
NPI:1861593592
Name:PEREZ, ROLANDO (IMG, LSA)
Entity type:Individual
Prefix:MR
First Name:ROLANDO
Middle Name:
Last Name:PEREZ
Suffix:
Gender:M
Credentials:IMG, LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7546
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61126-7546
Mailing Address - Country:US
Mailing Address - Phone:832-425-5634
Mailing Address - Fax:
Practice Address - Street 1:1491 STONY CREEK WAY
Practice Address - Street 2:APT 2
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-1210
Practice Address - Country:US
Practice Address - Phone:832-425-5634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00087207T00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery