Provider Demographics
NPI:1386645182
Name:LOPEZ-REVEROL, JAIME PEDRO (MD)
Entity Type:Individual
Prefix:DR
First Name:JAIME
Middle Name:PEDRO
Last Name:LOPEZ-REVEROL
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:INST SAN PABLO
Mailing Address - Street 2:SUITE 306
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00961-7041
Mailing Address - Country:US
Mailing Address - Phone:787-786-2690
Mailing Address - Fax:787-787-5413
Practice Address - Street 1:INST SAN PABLO SANTA CRUZ ST.#66
Practice Address - Street 2:SUITE 306
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961-7041
Practice Address - Country:US
Practice Address - Phone:787-786-2690
Practice Address - Fax:787-787-5413
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2008-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6830174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRD08773Medicare UPIN