Healthcare Provider Details

I. General information

NPI: 1245886621
Provider Name (Legal Business Name): IVAN J PEREZ VICENTE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2019
Last Update Date: 08/09/2026
Certification Date: 08/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

736 CAMBRIDGE ST
BRIGHTON MA
02135-2907
US

IV. Provider business mailing address

PO BOX 365067
SAN JUAN PR
00936-5067
US

V. Phone/Fax

Practice location:
  • Phone: 617-789-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number25103
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number3019459
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: