Healthcare Provider Details

I. General information

NPI: 1104891738
Provider Name (Legal Business Name): MARIO FERNANDO PEREZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 02/07/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FARMINGTON AVE
FARMINGTON CT
06030-2200
US

IV. Provider business mailing address

800 BRADBURY DR SE STE 116
ALBUQUERQUE NM
87106-4310
US

V. Phone/Fax

Practice location:
  • Phone: 860-679-8300
  • Fax: 860-679-8344
Mailing address:
  • Phone: 505-272-1476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number041291
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number041291
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberMD2024-1021
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: