Provider Demographics
NPI:1124095757
Name:PEREZ, RICARDO (MD)
Entity type:Individual
Prefix:DR
First Name:RICARDO
Middle Name:
Last Name:PEREZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 OAK PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-2220
Mailing Address - Country:US
Mailing Address - Phone:708-788-0101
Mailing Address - Fax:708-788-0109
Practice Address - Street 1:2215 OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-2220
Practice Address - Country:US
Practice Address - Phone:708-788-0101
Practice Address - Fax:708-788-0109
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-02
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036108945207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036108945Medicaid
IL036108945Medicaid
IL206200Medicare ID - Type Unspecified