Healthcare Provider Details

I. General information

NPI: 1679679872
Provider Name (Legal Business Name): ERNESTO J PEREZ MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 08/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 6TH STREET SE
WINTER HAVEN FL
33880-4505
US

IV. Provider business mailing address

1450 6TH STREET SE
WINTER HAVEN FL
33880-4505
US

V. Phone/Fax

Practice location:
  • Phone: 863-299-1485
  • Fax: 863-291-3572
Mailing address:
  • Phone: 863-299-1485
  • Fax: 863-291-3572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberME0055358
License Number StateFL

VIII. Authorized Official

Name: ERNESTO J PEREZ
Title or Position: OWNER
Credential: MD
Phone: 863-299-1485