Healthcare Provider Details

I. General information

NPI: 1376747204
Provider Name (Legal Business Name): MARIO LAURO PEREZ D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 10/13/2021
Certification Date: 10/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9958 SIERRA AVE.
FONTANA CA
92335
US

IV. Provider business mailing address

33858 GOLDEN CROWN WAY
YUCAIPA CA
92399-6964
US

V. Phone/Fax

Practice location:
  • Phone: 909-427-3077
  • Fax:
Mailing address:
  • Phone: 909-797-7017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number20A8963
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20A8963
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: