Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 16896 | PR |
Y | 207Q00000X | Family Doctor | 25MA08784100 | NJ |
NPI | 1003081076 |
---|---|
Provider Name | Dr. Raul Iluminado Perez |
First Address | Elizabeth, NJ 07202-2601 |
Second Address | Elizabeth, NJ 07202-2601 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/04/2008 |
Last Update Date | 19/02/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0253651 | (05) | NJ |