MEDICARE: KEYSHA MARIE LOPEZ VEGA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	21131	PR
2	390200000X	Student in an Organized Health Care Education/Training Program	TL.0008177	CO
3	207RN0300X	Nephrology Physician	21131	PR

General Provider Information

NPI Number	:	1487041596
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEYSHA MARIE LOPEZ VEGA MD

Provider Business Mailing Address
First Line	:	1033 CALLE CERRO SALIENTE
Second Line	:	URB. QUINTAS DE ALTAMIRA
City	:	JUANA DIAZ
State	:	PR
Zip	:	00795-9107
Country	:	US
Telephone Number	:	787-316-3753
Fax Number	:

Provider Business Practice Location Address
First Line	:	155 AVE ARTERIAL HOSTOS APT 222
Second Line	:
City	:	SAN JUAN
State	:	PR
Zip	:	00918-2938
Country	:	US
Telephone Number	:	787-316-3753
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/16/2015
Last Update Date	:	07/06/2021

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