Provider Demographics
NPI:1316086317
Name:PEROSSA, SERGIO GIOVANNI (MD)
Entity type:Individual
Prefix:
First Name:SERGIO
Middle Name:GIOVANNI
Last Name:PEROSSA
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 1:10720 BARKER CYPRESS RD
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77433-1372
Mailing Address - Country:US
Mailing Address - Phone:281-345-4800
Mailing Address - Fax:281-345-4803
Practice Address - Street 1:10720 BARKER CYPRESS RD
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:TX
Practice Address - Zip Code:77433-1372
Practice Address - Country:US
Practice Address - Phone:281-345-4800
Practice Address - Fax:281-345-4803
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2004-0381207R00000X
TXM9576207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8W2435OtherBLUE CROSS BLUE SHIELD OF TEXAS
TX8W2435OtherBLUE CROSS BLUE SHIELD OF TEXAS