Provider Demographics
NPI:1285121558
Name:PERALES TREJO, INDIRA LIZZETH
Entity type:Individual
Prefix:
First Name:INDIRA LIZZETH
Middle Name:
Last Name:PERALES TREJO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 DUNVALE RD APT 6106
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77063-4466
Mailing Address - Country:US
Mailing Address - Phone:832-335-6921
Mailing Address - Fax:
Practice Address - Street 1:2810 W EXPRESSWAY 83
Practice Address - Street 2:
Practice Address - City:MERCEDES
Practice Address - State:TX
Practice Address - Zip Code:78570-9704
Practice Address - Country:US
Practice Address - Phone:956-973-3531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-22
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT2470207Q00000X
TXBP10063188390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program