Healthcare Provider Details

I. General information

NPI: 1871750604
Provider Name (Legal Business Name): JUAN DIEGO LOZANO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JUAN DIEGO LOZANO VARGAS MD

II. Dates (important events)

Enumeration Date: 05/20/2008
Last Update Date: 08/09/2023
Certification Date: 08/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 TORRANCE BLVD
TORRANCE CA
90503-4607
US

IV. Provider business mailing address

816 W CANNON ST
FORT WORTH TX
76104-3194
US

V. Phone/Fax

Practice location:
  • Phone: 310-374-8191
  • Fax: 310-303-6834
Mailing address:
  • Phone: 817-321-0404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberME112580
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberA144652
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License NumberME112580
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME112580
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA144652
License Number StateCA
# 6
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberU3583
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: