MEDICARE: DR. WALTER DANIEL PEREZ MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	036-097752	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	363661051	OTHER	IL	FEDERAL ID
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	01636255	OTHER	IL	BLUE CROSS BLUE SHIELD IL

General Provider Information

NPI Number	:	1558475996
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WALTER DANIEL PEREZ MD

Provider Business Mailing Address
First Line	:	625 S CHATHAM AVE
Second Line	:
City	:	ELMHURST
State	:	IL
Zip	:	60126-4046
Country	:	US
Telephone Number	:	630-359-4553
Fax Number	:	630-359-4552

Provider Business Practice Location Address
First Line	:	2859 S PULASKI RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60623-4456
Country	:	US
Telephone Number	:	773-762-3333
Fax Number	:	773-762-5555

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2006
Last Update Date	:	02/24/2012

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