Provider Demographics
NPI:1205833274
Name:MENDEZ -LOPEZ, JORGE (MD)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:
Last Name:MENDEZ -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 1:1640 CALLE TAMESIS
Mailing Address - Street 2:EL PARAISO
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-2953
Mailing Address - Country:US
Mailing Address - Phone:787-402-3757
Mailing Address - Fax:787-292-6953
Practice Address - Street 1:41 CALLE PISCIS
Practice Address - Street 2:URB. LOS ANGELES
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00979-1620
Practice Address - Country:US
Practice Address - Phone:787-791-5712
Practice Address - Fax:787-253-3689
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-05
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR14861208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR14861OtherSTATE MEDICAL LICENSE
PR0021708Medicare PIN
PRH96097Medicare UPIN