Healthcare Provider Details

I. General information

NPI: 1972579084
Provider Name (Legal Business Name): OSVALDO G. DE LA LUZ SR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

89 AVE DE DIEGO STE. 105
SAN JUAN PR
00927-6372
US

IV. Provider business mailing address

89 AVE DE DIEGO STE. 105
SAN JUAN PR
00927-6372
US

V. Phone/Fax

Practice location:
  • Phone: 787-764-9139
  • Fax: 787-764-6479
Mailing address:
  • Phone: 787-764-9139
  • Fax: 787-764-6479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number9571
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: