Healthcare Provider Details

I. General information

NPI: 1285811166
Provider Name (Legal Business Name): MARIA T PEREZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2008
Last Update Date: 01/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2003 W FULTON ST STE 303
CHICAGO IL
60612-2345
US

IV. Provider business mailing address

2003 W FULTON ST STE 303
CHICAGO IL
60612-2345
US

V. Phone/Fax

Practice location:
  • Phone: 312-243-2223
  • Fax:
Mailing address:
  • Phone: 618-662-2191
  • Fax: 618-662-2191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-098979
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: