MEDICARE: MR. JAY LOPEZ GOZUM NP

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	F0411057	CA

General Provider Information

NPI Number	:	1841538469
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAY LOPEZ GOZUM NP

Provider Business Mailing Address
First Line	:	1410 MARBLE CANYON WAY
Second Line	:
City	:	CHULA VISTA
State	:	CA
Zip	:	91915-1646
Country	:	US
Telephone Number	:	619-302-3893
Fax Number	:

Provider Business Practice Location Address
First Line	:	3202 DUKE ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92110-5401
Country	:	US
Telephone Number	:	619-302-3893
Fax Number	:

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

Provider Enumeration Date	:	01/17/2013
Last Update Date	:	01/17/2013

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