Provider Demographics
NPI:1871566778
Name:PEREZ, BENITO B JR (MD)
Entity type:Individual
Prefix:DR
First Name:BENITO
Middle Name:B
Last Name:PEREZ
Suffix:JR
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 1:12815 HEACOCK ST
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-3116
Mailing Address - Country:US
Mailing Address - Phone:951-972-7393
Mailing Address - Fax:
Practice Address - Street 1:12815 HEACOCK ST
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-3116
Practice Address - Country:US
Practice Address - Phone:951-972-7393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-10
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01054872207Q00000X
CAC52990207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200361810Medicaid
184520UUMedicare ID - Type Unspecified