Provider Demographics
NPI:1386399194
Name:PEREZ, INMACULADA C
Entity type:Individual
Prefix:
First Name:INMACULADA
Middle Name:C
Last Name:PEREZ
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 1:5319 CASTOR AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19124-1022
Mailing Address - Country:US
Mailing Address - Phone:215-869-9094
Mailing Address - Fax:
Practice Address - Street 1:3803-05 N 5TH
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140
Practice Address - Country:US
Practice Address - Phone:215-539-2473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-21
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01OtherMEDICARE
PA2ERKPOtherYES