Provider Demographics
NPI:1053777698
Name:PEREZ, ALFONSO II (PTA)
Entity type:Individual
Prefix:
First Name:ALFONSO
Middle Name:
Last Name:PEREZ
Suffix:II
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1604 CAMARINOS DR
Mailing Address - Street 2:
Mailing Address - City:EAGLE PASS
Mailing Address - State:TX
Mailing Address - Zip Code:78852-5562
Mailing Address - Country:US
Mailing Address - Phone:830-325-2952
Mailing Address - Fax:
Practice Address - Street 1:1310 37TH ST
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-4860
Practice Address - Country:US
Practice Address - Phone:830-325-2952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-12
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 26376174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist