Basic Information
| Provider Information | |||||||||
| NPI: | 1184727232 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PEREZ | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | CECILE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 SKILLMAN AVE | ||||||||
| Address2: | LUTHERAN FAMILY HLTH CTR. - COMMUNITY MEDICINE PROGRAM | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112111607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183027333 | ||||||||
| FaxNumber: | 7189634016 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 SKILLMAN AVE | ||||||||
| Address2: | LUTHERAN FAMILY HLTH CTR. - COMMUNITY MEDICINE PROGRAM | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112111607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183027333 | ||||||||
| FaxNumber: | 7189634016 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2006 | ||||||||
| LastUpdateDate: | 10/30/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 196206 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02202826 | 05 | NY | MEDICAID |