MEDICARE: JOSE LUIS QUIROGA PSY.D.

Medicare Provider Information

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY17172	CA

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	ZZZ92069Z	OTHER	CA	MEDICARE GROUP ID#
3	ZZZ91891Z	OTHER	CA	MEDICARE GROUP ID#
4	ZZZ92073Z	OTHER	CA	MEDICARE GROUP ID#
6	ZZZ91892Z	OTHER	CA	MEDICARE GROUP ID#

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1659315430	OTHER	CA	LEGAL ENTITY NPI#
5	PSY17172	OTHER	CA	CLINICAL PSYCHOLOGIST

NPI Number	:	1417991373
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSE LUIS QUIROGA PSY.D.

Provider Business Mailing Address
First Line	:	1400 EMELINE AVE
Second Line	:
City	:	SANTA CRUZ
State	:	CA
Zip	:	95060-1976
Country	:	US
Telephone Number	:	831-454-4170
Fax Number	:	831-454-4971

Provider Business Practice Location Address
First Line	:	1400 EMELINE AVE
Second Line	:
City	:	SANTA CRUZ
State	:	CA
Zip	:	95060-1976
Country	:	US
Telephone Number	:	831-454-4170
Fax Number	:	831-454-4971

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2006
Last Update Date	:	03/11/2008

1400 EMELINE AVE BLDG K
SANTA CRUZ, CA
95060-1976

Practice Phone: 831-454-4170
Practice Fax:

1400 EMELINE AVE
SANTA CRUZ, CA
95060-1976