Healthcare Provider Details

I. General information

NPI: 1073588349
Provider Name (Legal Business Name): JOSE ANGEL LIZASOAIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 03/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MAYOR ST 2651 DR JOSE A LIZASOGIN OFFICE
PONCE PR
00717-2072
US

IV. Provider business mailing address

PO BOX 336060 MAYOR ST 2651
PONCE PR
00717-2072
US

V. Phone/Fax

Practice location:
  • Phone: 787-840-8383
  • Fax: 787-840-1582
Mailing address:
  • Phone: 787-840-8383
  • Fax: 787-840-1582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4277
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: