Provider Demographics
NPI:1639202039
Name:LOPEZ, JOSE LUIS
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:LUIS
Last Name:LOPEZ
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 1:1019 CALLE NAVARRA
Mailing Address - Street 2:VISTA MAR
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00983-1642
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1324 CALLE CANADA
Practice Address - Street 2:ANTIGUO HOSP DE VETERANO PUERTO NUEVO
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00920-3860
Practice Address - Country:US
Practice Address - Phone:787-791-1551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR18571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0057612Medicaid