Basic Information
| Provider Information | |||||||||
| NPI: | 1851387435 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PEREA | ||||||||
| FirstName: | JAIME | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 700 | ||||||||
| Address2: | |||||||||
| City: | HEMET | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925460788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9519296260 | ||||||||
| FaxNumber: | 9517652855 | ||||||||
| Practice Location | |||||||||
| Address1: | 2390 E FLORIDA AVE | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | HEMET | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925444707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9514920900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2005 | ||||||||
| LastUpdateDate: | 05/23/2011 | ||||||||
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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 | 207V00000X | 036091579 | IL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | G72724 | 05 | IL | MEDICAID |