=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164545992
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAPHAEL E PEREZ O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2007
-----------------------------------------------------
Last Update Date | 03/12/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1120 SW 8TH ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33130-3604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-853-1079
-----------------------------------------------------
Fax | 305-860-3088
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 524 FERNWOOD RD
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33149-1842
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-853-1079
-----------------------------------------------------
Fax | 305-860-3088
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPC3418
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------