Healthcare Provider Details

I. General information

NPI: 1467669325
Provider Name (Legal Business Name): MR. JORGE LAZARO PEREZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13055 SW 42ND ST SUITE 206
MIAMI FL
33175-3406
US

IV. Provider business mailing address

13055 SW 42ND ST SUITE 206
MIAMI FL
33175-3406
US

V. Phone/Fax

Practice location:
  • Phone: 305-519-6268
  • Fax: 305-559-1633
Mailing address:
  • Phone: 305-519-6268
  • Fax: 305-559-1633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471V0105X
TaxonomyVascular Sonography Radiologic Technologist
License NumberRCVT2380
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: