Provider Demographics
NPI:1760475024
Name:JORDAN LOPEZ, OCTAVIO (MD)
Entity Type:Individual
Prefix:DR
First Name:OCTAVIO
Middle Name:
Last Name:JORDAN 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:EDIF MEDICO SANTA CRUZ
Mailing Address - Street 2:SUITE 313
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00961-6910
Mailing Address - Country:US
Mailing Address - Phone:787-780-7832
Mailing Address - Fax:787-798-1445
Practice Address - Street 1:EDIF MEDICO SANTA CRUZ
Practice Address - Street 2:SUITE 313
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961-6910
Practice Address - Country:US
Practice Address - Phone:787-780-7832
Practice Address - Fax:787-798-1445
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3658174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRD32934Medicare UPIN