Healthcare Provider Details

I. General information

NPI: 1730183187
Provider Name (Legal Business Name): EDGARD L PEREIRA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 06/27/2024
Certification Date: 06/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17387 BALARIA ST
BOCA RATON FL
33496-3279
US

IV. Provider business mailing address

17387 BALARIA ST
BOCA RATON FL
33496-3279
US

V. Phone/Fax

Practice location:
  • Phone: 561-312-0057
  • Fax: 954-239-3902
Mailing address:
  • Phone: 561-312-0057
  • Fax: 954-239-3902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberME104596
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number36956
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: