Provider Demographics
NPI:1487396156
Name:PERERA, PHILIP
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:
Last Name:PERERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30883 N GLORY GRV
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85143-3124
Mailing Address - Country:US
Mailing Address - Phone:858-504-0916
Mailing Address - Fax:
Practice Address - Street 1:30883 N GLORY GRV
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85143-3124
Practice Address - Country:US
Practice Address - Phone:858-504-0916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-12
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171832084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry