Provider Demographics
NPI:1417991373
Name:QUIROGA, JOSE LUIS (PSYD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:LUIS
Last Name:QUIROGA
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 EMELINE AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-1976
Mailing Address - Country:US
Mailing Address - Phone:831-454-4170
Mailing Address - Fax:831-454-4971
Practice Address - Street 1:1400 EMELINE AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-1976
Practice Address - Country:US
Practice Address - Phone:831-454-4170
Practice Address - Fax:831-454-4971
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17172103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1659315430OtherLEGAL ENTITY NPI#
CAZZZ92069ZOtherMEDICARE GROUP ID#
CAZZZ91891ZOtherMEDICARE GROUP ID#
CAZZZ92073ZOtherMEDICARE GROUP ID#
CAPSY17172OtherCLINICAL PSYCHOLOGIST
CAZZZ91892ZOtherMEDICARE GROUP ID#
CAZZZ92069ZOtherMEDICARE GROUP ID#