Provider Demographics
NPI:1093989477
Name:JUAN, NORBERTO L (MD)
Entity Type:Individual
Prefix:
First Name:NORBERTO
Middle Name:L
Last Name:JUAN
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 1:11009 DETROIT AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44102-2412
Mailing Address - Country:US
Mailing Address - Phone:216-228-1729
Mailing Address - Fax:216-228-1740
Practice Address - Street 1:3745 GROVE AVE.
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44055
Practice Address - Country:US
Practice Address - Phone:440-240-1655
Practice Address - Fax:440-233-0194
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-16
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35040166207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0335104Medicaid