Provider Demographics
NPI:1144309600
Name:LOPEZ, JORGE (MD)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:E20 CALLE TABONUCO
Mailing Address - Street 2:ARBOLADA
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00727-1306
Mailing Address - Country:US
Mailing Address - Phone:939-397-2065
Mailing Address - Fax:787-743-2067
Practice Address - Street 1:AVE. LUIS MUNOZ MARIN
Practice Address - Street 2:X-14 MARIOLGA
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725
Practice Address - Country:US
Practice Address - Phone:787-743-2067
Practice Address - Fax:787-743-2067
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR14939208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR22055Medicare ID - Type UnspecifiedMEDICARE
PRH-98261Medicare UPIN