Healthcare Provider Details

I. General information

NPI: 1205833274
Provider Name (Legal Business Name): JORGE MENDEZ -LOPEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 11/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 CALLE PISCIS URB. LOS ANGELES
CAROLINA PR
00979-1620
US

IV. Provider business mailing address

1640 CALLE TAMESIS EL PARAISO
SAN JUAN PR
00926-2953
US

V. Phone/Fax

Practice location:
  • Phone: 787-791-5712
  • Fax: 787-253-3689
Mailing address:
  • Phone: 787-402-3757
  • Fax: 787-292-6953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number14861
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: