=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063745131
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JORGE A PEREZ LOPEZ MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2009
-----------------------------------------------------
Last Update Date | 04/08/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 N CLYDE MORRIS BLVD SUITE 120
-----------------------------------------------------
City | DAYTONA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32114-2765
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-425-4641
-----------------------------------------------------
Fax | 386-947-4647
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 732901
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75373-2901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-226-4590
-----------------------------------------------------
Fax | 386-226-3371
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | ME116773
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------