Basic Information
| Provider Information | |||||||||
| NPI: | 1639110638 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PERRY | ||||||||
| FirstName: | MELVIN | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT 409 PO BOX 4346 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 772104346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105586288 | ||||||||
| FaxNumber: | 2105586289 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 MADISON OAK DR | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782583913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105586288 | ||||||||
| FaxNumber: | 2105586289 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 06/08/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0203X | 49276-020 | WI | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine | 2080P0203X | M9577 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine | 208000000X | 022738 | LA | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0203X | O4-30600 | KS | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine | 2080P0203X | 046470 | GA | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine | 2080P0203X | 022738 | LA | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine | 2080P0203X | 2004025527 | MO | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine | 2080P0203X | 40058 | TN | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine | 2080P0203X | 435456 | PA | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine | 2080P0203X | 35.083485 | OH | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine | 2080P0203X | 01057110A | IN | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1492574 | 05 | LA | MEDICAID |