1871750604 NPI number — JUAN DIEGO LOZANO MD

Table of content: JUAN DIEGO LOZANO MD (NPI 1871750604)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871750604 NPI number — JUAN DIEGO LOZANO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOZANO
Provider First Name:
JUAN
Provider Middle Name:
DIEGO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LOZANO VARGAS
Provider Other First Name:
JUAN
Provider Other Middle Name:
DIEGO
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1871750604
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
816 W CANNON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76104-3194
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-321-0404
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4101 TORRANCE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TORRANCE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90503-4607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-374-8191
Provider Business Practice Location Address Fax Number:
310-303-6834
Provider Enumeration Date:
05/20/2008

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: 2085N0700X , with the licence number:  ME112580 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085N0700X , with the licence number: A144652 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085N0904X , with the licence number: ME112580 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: ME112580 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: A144652 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085N0700X , with the licence number: U3583 , 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: M6074 . This is a "MEDICARE HF" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 024978900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".