Provider Demographics
NPI:1083834139
Name:OVALLES JAQUEZ, JOSE R
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:R
Last Name:OVALLES JAQUEZ
Suffix:
Gender:M
Credentials:
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 70344
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00936-8344
Mailing Address - Country:US
Mailing Address - Phone:787-692-4080
Mailing Address - Fax:
Practice Address - Street 1:CALLE PADRE LAS CASAS #107 URBANIZACION EL VEDADO
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918
Practice Address - Country:US
Practice Address - Phone:787-767-8758
Practice Address - Fax:844-759-2966
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-30
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR007219207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR37848501Medicaid