Basic Information
| Provider Information | |||||||||
| NPI: | 1972248177 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEREZ | ||||||||
| FirstName: | MARCOS | ||||||||
| MiddleName: | AUSTIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13029 DUSTY RD | ||||||||
| Address2: | |||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923926335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6268729001 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1481 WINDSOR DR | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924045416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093616470 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2022 | ||||||||
| LastUpdateDate: | 05/02/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | 193400000X SINGLE SPECIALTY GROUP | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.