Provider Demographics
NPI:1962424135
Name:PEREZ, FREDY (OD)
Entity type:Individual
Prefix:DR
First Name:FREDY
Middle Name:
Last Name:PEREZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 MAVIS DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90065-5014
Mailing Address - Country:US
Mailing Address - Phone:323-227-5490
Mailing Address - Fax:
Practice Address - Street 1:1509 SUNSET BL.
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026
Practice Address - Country:US
Practice Address - Phone:213-250-5768
Practice Address - Fax:213-250-5773
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA06315 T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0063150Medicaid
CA72215Medicare ID - Type UnspecifiedMEDICARE SUBMITTER NO.
CASD0063150Medicaid
CAWOP6315BMedicare PIN