Basic Information
| Provider Information | |||||||||
| NPI: | 1629188586 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PEREZ | ||||||||
| FirstName: | GASTON | ||||||||
| MiddleName: | O. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. F.A.A.F.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14 OAK FOREST RD | ||||||||
| Address2: | SUITE D | ||||||||
| City: | BLUFFTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299104988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438156468 | ||||||||
| FaxNumber: | 8438156492 | ||||||||
| Practice Location | |||||||||
| Address1: | 14 OAK FOREST RD | ||||||||
| Address2: | SUITE D | ||||||||
| City: | BLUFFTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299104988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438156468 | ||||||||
| FaxNumber: | 8438156492 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 10/10/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 17810 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 17814 | 05 | SC | MEDICAID |