Provider Demographics
NPI:1811940380
Name:LLERENA-RIQUELME, JOSE MARCELO (MD)
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:MARCELO
Last Name:LLERENA-RIQUELME
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JOSE
Other - Middle Name:MARCELO
Other - Last Name:LLERENA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9500 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44195-5503
Mailing Address - Country:US
Mailing Address - Phone:216-448-0621
Mailing Address - Fax:216-448-0220
Practice Address - Street 1:9500 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44195-5503
Practice Address - Country:US
Practice Address - Phone:216-448-0621
Practice Address - Fax:216-448-0220
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK44882085R0204X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX059227108Medicaid
TX059227108Medicaid
F95742Medicare UPIN
TX8K6419Medicare PIN