Healthcare Provider Details

I. General information

NPI: 1528392321
Provider Name (Legal Business Name): JUAN CARLOS L PEREZ LOZADA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2009
Last Update Date: 05/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 YORK ST SPC 2-213
NEW HAVEN CT
06510-3220
US

IV. Provider business mailing address

20 YORK ST SPC 2-213
NEW HAVEN CT
06510-3220
US

V. Phone/Fax

Practice location:
  • Phone: 203-785-7026
  • Fax: 203-737-1077
Mailing address:
  • Phone: 203-785-7026
  • Fax: 203-737-1077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number051271
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number051271
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: