Provider Demographics
NPI:1386622306
Name:PEREZ, PABLO M (MD)
Entity type:Individual
Prefix:DR
First Name:PABLO
Middle Name:M
Last Name:PEREZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3640 NEW VISION DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1717
Mailing Address - Country:US
Mailing Address - Phone:260-482-4440
Mailing Address - Fax:260-482-4442
Practice Address - Street 1:2200 RANDALLIA DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4638
Practice Address - Country:US
Practice Address - Phone:260-373-4000
Practice Address - Fax:260-482-4442
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042609207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000033415OtherMPLAN
IN200044880Medicaid
IN000000379802OtherANTHEM
OH2614282Medicaid
MI104874641Medicaid
IN047840QQQQMedicare ID - Type Unspecified
MI104874641Medicaid
IN000000379802OtherANTHEM