Basic Information
| Provider Information | |||||||||
| NPI: | 1639171853 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEREZ | ||||||||
| FirstName: | AIXSA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 955 S WOODLAND BLVD STE A1 | ||||||||
| Address2: | |||||||||
| City: | DELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327207321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8552266633 | ||||||||
| FaxNumber: | 8662857068 | ||||||||
| Practice Location | |||||||||
| Address1: | 955 S WOODLAND BLVD STE A1 | ||||||||
| Address2: | |||||||||
| City: | DELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327207321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8552266633 | ||||||||
| FaxNumber: | 8662857068 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2005 | ||||||||
| LastUpdateDate: | 04/28/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01049434A | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | 208D00000X | ACN1112 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 102864500 | 05 | FL | MEDICAID |