Provider Demographics
NPI:1063745131
Name:PEREZ LOPEZ, JORGE A (MD)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:A
Last Name:PEREZ LOPEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 732901
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-2901
Mailing Address - Country:US
Mailing Address - Phone:386-226-4590
Mailing Address - Fax:386-226-3371
Practice Address - Street 1:201 N CLYDE MORRIS BLVD
Practice Address - Street 2:SUITE 120
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2765
Practice Address - Country:US
Practice Address - Phone:386-425-4641
Practice Address - Fax:386-947-4647
Is Sole Proprietor?:No
Enumeration Date:2009-09-08
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME116773208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation