Healthcare Provider Details

I. General information

NPI: 1255438347
Provider Name (Legal Business Name): VIRGILIO IGNACIO LOPEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 06/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 ROUTE 3
DEDEDO GU
96929-6911
US

IV. Provider business mailing address

PO BOX 11258
TAMUNING GU
96931-1258
US

V. Phone/Fax

Practice location:
  • Phone: 671-645-5500
  • Fax:
Mailing address:
  • Phone: 671-688-8181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number9341
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberM-1774
License Number StateGU

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: