Healthcare Provider Details

I. General information

NPI: 1467011452
Provider Name (Legal Business Name): JOSE ERNESTO LOPEZ VALENCIA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2019
Last Update Date: 10/08/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6720 BERTNER AVE
HOUSTON TX
77030-2604
US

IV. Provider business mailing address

55 FRUIT ST
BOSTON MA
02114-2696
US

V. Phone/Fax

Practice location:
  • Phone: 823-355-2666
  • Fax:
Mailing address:
  • Phone: 617-726-3030
  • Fax: 617-726-3030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberV3370
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License NumberV3370
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number1013986
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: