Provider Demographics
NPI:1447272299
Name:PEREZ-LOPEZ, EDWIN (MD)
Entity type:Individual
Prefix:MR
First Name:EDWIN
Middle Name:
Last Name:PEREZ-LOPEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83 WELLNESS WAY STE 101&201
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:KY
Mailing Address - Zip Code:42025-7156
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:83 WELLNESS WAY STE 101&201
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:KY
Practice Address - Zip Code:42025-7156
Practice Address - Country:US
Practice Address - Phone:270-527-0045
Practice Address - Fax:270-527-9615
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39144207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64106602Medicaid
I31190Medicare UPIN
KYK056341Medicare PIN