Basic Information
| Provider Information | |||||||||
| NPI: | 1811243397 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PERSE | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 932127 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441930008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2163632730 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10553 SAINT CLAIR AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441081973 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2166827702 | ||||||||
| FaxNumber: | 2169206273 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2012 | ||||||||
| LastUpdateDate: | 02/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 36-003674 | OH | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0085043 | 05 | OH | MEDICAID |