Basic Information
| Provider Information | |||||||||
| NPI: | 1710023668 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARLO-IZQUIERDO | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | RAFAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | URB. SAN FRANCISCO 1712 LILAS ST. | ||||||||
| Address2: | |||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877644474 | ||||||||
| FaxNumber: | 7877540474 | ||||||||
| Practice Location | |||||||||
| Address1: | PPMI-RCM AVE. AMERICO MIRANDA APTDO. 19134 | ||||||||
| Address2: | CENTRO MEDICO DE PR EDIF PRINCIPAL ESCUELA DE MEDICINA | ||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877582525 | ||||||||
| FaxNumber: | 7877540474 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 7092 | PR | X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084P2900X | 7092 | PR | X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7092 | 01 | PR | STATE LICENSE | OTHER |