=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760465371
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARLOS M PEREZ MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2005
-----------------------------------------------------
Last Update Date | 06/06/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1704 MERMAID AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11224-2622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-265-0900
-----------------------------------------------------
Fax | 718-265-6319
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1145 TARGEE STREET
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-668-6900
-----------------------------------------------------
Fax | 718-668-6900
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 097912
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------