Basic Information
| Provider Information | |||||||||
| NPI: | 1063745131 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PEREZ LOPEZ | ||||||||
| FirstName: | JORGE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 732901 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753732901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862264590 | ||||||||
| FaxNumber: | 3862263371 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 N CLYDE MORRIS BLVD | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321142765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3864254641 | ||||||||
| FaxNumber: | 3869474647 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2009 | ||||||||
| LastUpdateDate: | 04/08/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | ME116773 | FL | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.