Provider Demographics
NPI:1043558547
Name:CONSULTORIO MEDICO M L O INC
Entity Type:Organization
Organization Name:CONSULTORIO MEDICO M L O INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:LOURDES
Authorized Official - Last Name:ORTIZ DE LA CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-597-6987
Mailing Address - Street 1:PO BOX 142784
Mailing Address - Street 2:
Mailing Address - City:ARECIBO
Mailing Address - State:PR
Mailing Address - Zip Code:00614-2784
Mailing Address - Country:US
Mailing Address - Phone:787-650-1363
Mailing Address - Fax:787-650-1363
Practice Address - Street 1:CAR 129 KM 37 H7 BO HATO ARRIBA-DENKTON
Practice Address - Street 2:
Practice Address - City:ARECIBO
Practice Address - State:PR
Practice Address - Zip Code:00612
Practice Address - Country:US
Practice Address - Phone:787-650-1353
Practice Address - Fax:787-650-1353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-18
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR14416261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRI-07393Medicare UPIN