1811940380 NPI number — DR. JOSE MARCELO LLERENA-RIQUELME M.D.

Table of content: DR. JOSE MARCELO LLERENA-RIQUELME M.D. (NPI 1811940380)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811940380 NPI number — DR. JOSE MARCELO LLERENA-RIQUELME M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LLERENA-RIQUELME
Provider First Name:
JOSE
Provider Middle Name:
MARCELO
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LLERENA
Provider Other First Name:
JOSE
Provider Other Middle Name:
MARCELO
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1811940380
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/25/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9500 EUCLID AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44195-5503
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-448-0621
Provider Business Mailing Address Fax Number:
216-448-0220

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9500 EUCLID AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44195-5503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-448-0621
Provider Business Practice Location Address Fax Number:
216-448-0220
Provider Enumeration Date:
05/18/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0204X , with the licence number:  K4488 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: K4488 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 059227108 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".