=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326344870
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RAPHAEL E PEREZ MD OD MBA INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2011
-----------------------------------------------------
Last Update Date | 11/24/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11466 S.W. QUAIL ROOST DRIVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33157
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-255-8559
-----------------------------------------------------
Fax | 305-255-7880
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 524 FERNWOOD ROAD
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33149-1842
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-255-8559
-----------------------------------------------------
Fax | 305-255-7880
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. RAPHAEL E. PEREZ
-----------------------------------------------------
Credential | M.D., O.D, MBA
-----------------------------------------------------
Telephone | 786-853-1079
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------