Provider Demographics
NPI:1669957510
Name:PEREZ, DEANDRA
Entity type:Individual
Prefix:MRS
First Name:DEANDRA
Middle Name:
Last Name:PEREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 BLAKLEY CT FL 1
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-5820
Mailing Address - Country:US
Mailing Address - Phone:956-854-1067
Mailing Address - Fax:
Practice Address - Street 1:16 BLAKLEY CT FL 1
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-5820
Practice Address - Country:US
Practice Address - Phone:956-854-1067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-26
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY174400000XMedicaid