Healthcare Provider Details

I. General information

NPI: 1174543599
Provider Name (Legal Business Name): JOSE A LOPEZ VELAZQUEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 09/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE RUFINA #3
GUAYANILLA PR
00656
US

IV. Provider business mailing address

PO BOX 560340
GUAYANILLA PR
00656-0340
US

V. Phone/Fax

Practice location:
  • Phone: 787-835-4756
  • Fax: 787-835-4756
Mailing address:
  • Phone: 787-835-4756
  • Fax: 787-835-4756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number10129
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: