Healthcare Provider Details

I. General information

NPI: 1245025444
Provider Name (Legal Business Name): ISMAEL PEREZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2025
Last Update Date: 04/10/2025
Certification Date: 04/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 WILFORD HALL LOOP BLDG 455459
JBSA LACKLAND TX
78236-5638
US

IV. Provider business mailing address

1100 WILFORD HALL LOOP BLDG 455459
JBSA LACKLAND TX
78236-5638
US

V. Phone/Fax

Practice location:
  • Phone: 210-292-5972
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: