Provider Demographics
NPI:1659394260
Name:LOPEZ, JORGE LUIS (MD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:LUIS
Last Name: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:PO BOX 1324
Mailing Address - Street 2:
Mailing Address - City:HORMIGUEROS
Mailing Address - State:PR
Mailing Address - Zip Code:00660-5324
Mailing Address - Country:US
Mailing Address - Phone:787-310-7994
Mailing Address - Fax:
Practice Address - Street 1:345 AVE HOSTOS
Practice Address - Street 2:
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680-1507
Practice Address - Country:US
Practice Address - Phone:787-834-6900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR64522084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry