Provider Demographics
NPI:1861738585
Name:PEREZ, ALTAGRACIA JOSEFINA (PA,SU, FOREIGN MD)
Entity type:Individual
Prefix:DR
First Name:ALTAGRACIA
Middle Name:JOSEFINA
Last Name:PEREZ
Suffix:
Gender:F
Credentials:PA,SU, FOREIGN MD
Other - Prefix:DR
Other - First Name:ALTAGRACIA
Other - Middle Name:JOSEFINA
Other - Last Name:PEREZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FOREIGN PATHOLOGIST
Mailing Address - Street 1:PO BOX 557635
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33255-7635
Mailing Address - Country:US
Mailing Address - Phone:305-975-7541
Mailing Address - Fax:305-225-8140
Practice Address - Street 1:1115 SW 11TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33129-1820
Practice Address - Country:US
Practice Address - Phone:305-975-7541
Practice Address - Fax:305-225-8140
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012984246Q00000X
FLSU41493246Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Q00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
M.D. 3907OtherFOREIGN M.D. & PATHOLOGIST (DOM. REP.)