Provider Demographics
NPI:1750845780
Name:MELENDEZ, JOSE ENRIQUE
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:ENRIQUE
Last Name:MELENDEZ
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 1:13 VILLA ENCANTADA
Mailing Address - Street 2:
Mailing Address - City:CIDRA
Mailing Address - State:PR
Mailing Address - Zip Code:00739-9562
Mailing Address - Country:US
Mailing Address - Phone:787-202-8328
Mailing Address - Fax:
Practice Address - Street 1:13 VILLA ENCANTADA
Practice Address - Street 2:
Practice Address - City:CIDRA
Practice Address - State:PR
Practice Address - Zip Code:00739-9562
Practice Address - Country:US
Practice Address - Phone:787-202-8328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2150267172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver