Provider Demographics
NPI:1982962007
Name:PEREZ, LEO ALEXANDER (SOIDC)
Entity type:Individual
Prefix:
First Name:LEO
Middle Name:ALEXANDER
Last Name:PEREZ
Suffix:
Gender:M
Credentials:SOIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2321 ROOKERY WAY
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-1559
Mailing Address - Country:US
Mailing Address - Phone:808-282-9529
Mailing Address - Fax:
Practice Address - Street 1:2321 ROOKERY WAY
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-1559
Practice Address - Country:US
Practice Address - Phone:808-282-9529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-26
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman