Healthcare Provider Details

I. General information

NPI: 1932859501
Provider Name (Legal Business Name): JORGE LUIS LOPEZ CUELLO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2022
Last Update Date: 04/03/2025
Certification Date: 04/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 1ST AVE BLDG RM704
NEW YORK NY
10029-7494
US

IV. Provider business mailing address

703 MAIN ST
PATERSON NJ
07503-2621
US

V. Phone/Fax

Practice location:
  • Phone: 212-423-6771
  • Fax: 212-423-8099
Mailing address:
  • Phone: 973-754-2431
  • Fax: 973-754-3376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: