Provider Demographics
NPI:1174543599
Name:LOPEZ VELAZQUEZ, JOSE A (MD)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:A
Last Name:LOPEZ VELAZQUEZ
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:PO BOX 560340
Mailing Address - Street 2:
Mailing Address - City:GUAYANILLA
Mailing Address - State:PR
Mailing Address - Zip Code:00656-0340
Mailing Address - Country:US
Mailing Address - Phone:787-835-4756
Mailing Address - Fax:787-835-4756
Practice Address - Street 1:CALLE RUFINA #3
Practice Address - Street 2:
Practice Address - City:GUAYANILLA
Practice Address - State:PR
Practice Address - Zip Code:00656
Practice Address - Country:US
Practice Address - Phone:787-835-4756
Practice Address - Fax:787-835-4756
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR10129208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRF87151Medicare UPIN
PR83152Medicare ID - Type Unspecified