Basic Information
Provider Information | |||||||||
NPI: | 1538398946 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PEREZ | ||||||||
FirstName: | OMAR | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PEREZ-CARILLO | ||||||||
OtherFirstName: | OMAR | ||||||||
OtherMiddleName: | M | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 9445 CALUMET AVE | ||||||||
Address2: |   | ||||||||
City: | MUNSTER | ||||||||
State: | IN | ||||||||
PostalCode: | 463212811 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2198361060 | ||||||||
FaxNumber: | 2198361014 | ||||||||
Practice Location | |||||||||
Address1: | 9445 CALUMET AVE | ||||||||
Address2: |   | ||||||||
City: | MUNSTER | ||||||||
State: | IN | ||||||||
PostalCode: | 463212811 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2198361060 | ||||||||
FaxNumber: | 2198361014 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/07/2009 | ||||||||
LastUpdateDate: | 06/09/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/30/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X |   |   | N |   | Other Service Providers | Specialist |   | 207XX0005X | 01077396A | IN | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
ID | Type | State | Issuer | Description | 1538398946 | 01 | IN | NPI | OTHER |