Healthcare Provider Details

I. General information

NPI: 1114990611
Provider Name (Legal Business Name): JOSE JAVIER LOPEZ BURREZO M. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

277 CALLE SAN JORGE SAN JORGE MEDICAL OFFICE BLDG SUITE 406
SAN JUAN PR
00912-3331
US

IV. Provider business mailing address

335 CALLE WEST ROSE URB. CIUDAD JARDIN
CAROLINA PR
00987-2222
US

V. Phone/Fax

Practice location:
  • Phone: 787-726-0210
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number12373
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: