Healthcare Provider Details

I. General information

NPI: 1407855372
Provider Name (Legal Business Name): JOSE LUIS LOPEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 02/29/2024
Certification Date: 02/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SARDINERA BEACH BUILDING, URB. COSTA DE ORO, C/MARGINAL SUITE 3
DORADO PR
00646-2055
US

IV. Provider business mailing address

PASEO DEL SOL 209 CALLE METIS
DORADO PR
00646-4618
US

V. Phone/Fax

Practice location:
  • Phone: 787-278-3636
  • Fax: 787-278-8494
Mailing address:
  • Phone: 787-405-6346
  • Fax: 787-278-8494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number13112
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: