Provider Demographics
NPI:1154343978
Name:PEREZ, DOMINGO A (MD)
Entity type:Individual
Prefix:DR
First Name:DOMINGO
Middle Name:A
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 1:100 GRAND BULEVARD PASEOS
Mailing Address - Street 2:SUITE 112 MSC 333
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-5955
Mailing Address - Country:US
Mailing Address - Phone:787-779-0484
Mailing Address - Fax:787-779-0484
Practice Address - Street 1:#68 AVE. SANTA CRUZ
Practice Address - Street 2:SUITE 405 TORRE SAN PABLO
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961
Practice Address - Country:US
Practice Address - Phone:787-779-0484
Practice Address - Fax:787-779-0484
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR9686207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRE81930Medicare UPIN
PR81723Medicare ID - Type Unspecified