Provider Demographics
NPI:1730100769
Name:WILMER PEREZ MD PC
Entity type:Organization
Organization Name:WILMER PEREZ MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:WILMER
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-542-5864
Mailing Address - Street 1:405 W 15TH ST
Mailing Address - Street 2:# 400
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003
Mailing Address - Country:US
Mailing Address - Phone:719-542-5864
Mailing Address - Fax:719-544-8450
Practice Address - Street 1:405 W 15TH ST
Practice Address - Street 2:# 400
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003
Practice Address - Country:US
Practice Address - Phone:719-542-5864
Practice Address - Fax:719-544-8450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO026305207R00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Not Answered207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO66508053Medicaid
COC801628Medicare ID - Type Unspecified
CO66508053Medicaid