Provider Demographics
NPI:1801830427
Name:VALDESUSO, JORGE (MD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:VALDESUSO
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:ARBOLES DE MONTEHIEDRA
Mailing Address - Street 2:BLVD 600 BOX 342
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926
Mailing Address - Country:US
Mailing Address - Phone:787-760-4425
Mailing Address - Fax:787-748-4036
Practice Address - Street 1:200 AVE CUPEY GARDENS SUITE 11 W
Practice Address - Street 2:CUPEY GARDENS PLAZA
Practice Address - City:SANJUAN
Practice Address - State:PR
Practice Address - Zip Code:00926
Practice Address - Country:US
Practice Address - Phone:787-760-4425
Practice Address - Fax:787-748-4036
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11470208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0084304Medicare ID - Type Unspecified
PRG43756Medicare UPIN