Provider Demographics
NPI:1720079189
Name:PEREZ LOPEZ, JESUS A (MD)
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:A
Last Name:PEREZ 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 5360
Mailing Address - Street 2:
Mailing Address - City:SAN SEBASTIAN
Mailing Address - State:PR
Mailing Address - Zip Code:00685-5360
Mailing Address - Country:US
Mailing Address - Phone:787-280-3655
Mailing Address - Fax:787-280-2776
Practice Address - Street 1:100 CALLE ELOY TORRES LUGO
Practice Address - Street 2:URB. EL PRADO
Practice Address - City:AGUADILLA
Practice Address - State:PR
Practice Address - Zip Code:00603-5842
Practice Address - Country:US
Practice Address - Phone:787-280-3655
Practice Address - Fax:787-280-2776
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-03
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11959208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR88484PEOtherTRIPLE S
PRPALICOtherPG3175
PR8707OtherFIRST MEDICAL
PR061517OtherBLUE CROSS BLUE SHIELD
PR201560OtherPREFERRED HEALTH
PR88454Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
PR1190Medicare ID - Type UnspecifiedPERFERRED MEDICARE CHOICE
PR061517OtherBLUE CROSS BLUE SHIELD
PR201560OtherPREFERRED HEALTH