Basic Information
| Provider Information | |||||||||
| NPI: | 1174504815 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PEREZ | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 REID PKWY | ||||||||
| Address2: | MEDICAL STAFF SERVICES | ||||||||
| City: | RICHMOND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473741157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7659358802 | ||||||||
| FaxNumber: | 7659833219 | ||||||||
| Practice Location | |||||||||
| Address1: | 1050 REID PKWY | ||||||||
| Address2: | SUITE 325 | ||||||||
| City: | RICHMOND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473741155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7659628551 | ||||||||
| FaxNumber: | 7659622591 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2005 | ||||||||
| LastUpdateDate: | 04/17/2015 | ||||||||
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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 | 208800000X | 01024969A | IN | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 0616220 | 05 | OH | MEDICAID | 000000705065 | 01 | IN | ANTHEM | OTHER | 100324610 | 05 | IN | MEDICAID |