Provider Demographics
NPI:1619166824
Name:ORTIZ LUGO, RAUL A (AUDIOLOGO)
Entity Type:Individual
Prefix:
First Name:RAUL
Middle Name:A
Last Name:ORTIZ LUGO
Suffix:
Gender:M
Credentials:AUDIOLOGO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5000
Mailing Address - Street 2:PMB 477
Mailing Address - City:SAN GERMAN
Mailing Address - State:PR
Mailing Address - Zip Code:00683-9800
Mailing Address - Country:US
Mailing Address - Phone:787-264-7027
Mailing Address - Fax:787-264-7027
Practice Address - Street 1:AVE ATLETICOS DE SAN GERMAN EDIFICIO RALI
Practice Address - Street 2:SUITE 204
Practice Address - City:SAN GERMAN
Practice Address - State:PR
Practice Address - Zip Code:00683-9800
Practice Address - Country:US
Practice Address - Phone:787-264-7027
Practice Address - Fax:787-264-7027
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-24
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR450174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRHH869AMedicare PIN