Healthcare Provider Details

I. General information

NPI: 1780004184
Provider Name (Legal Business Name): LESLIE ISABEL PEREZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2014
Last Update Date: 03/20/2023
Certification Date: 03/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 MAIN ST STE 3A
SENOIA GA
30276-1895
US

IV. Provider business mailing address

643 MAIN ST
PALMETTO GA
30268-1138
US

V. Phone/Fax

Practice location:
  • Phone: 678-723-0400
  • Fax: 770-599-9779
Mailing address:
  • Phone: 404-929-8824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301106164
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number84321
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: