Provider Demographics
NPI:1437615911
Name:LOPEZ RUIZ, JEAN
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:LOPEZ RUIZ
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 1:2321 CALLE UNIVERSIDAD COND EL MIRADOR
Mailing Address - Street 2:APT 1002
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00717
Mailing Address - Country:US
Mailing Address - Phone:917-704-0497
Mailing Address - Fax:
Practice Address - Street 1:2321 CALLE UNIVERSIDAD
Practice Address - Street 2:CONDOMINIO EL MIRADOR APT 1002
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00717-0071
Practice Address - Country:US
Practice Address - Phone:917-704-0497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-20
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR6064209Medicaid