Healthcare Provider Details

I. General information

NPI: 1396727715
Provider Name (Legal Business Name): ILEANA LOPEZ PLAZA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ILEANA LOPEZ MD

II. Dates (important events)

Enumeration Date: 11/20/2005
Last Update Date: 07/31/2007
Certification Date:
Deactivation Date: 07/17/2007
Reactivation Date: 07/31/2007

III. Provider practice location address

750 WASHINGTON ST #826
BOSTON MA
02111
US

IV. Provider business mailing address

750 WASHINGTON ST #826
BOSTON MA
02111
US

V. Phone/Fax

Practice location:
  • Phone: 617-636-5842
  • Fax: 617-636-3175
Mailing address:
  • Phone: 617-636-5842
  • Fax: 617-636-3175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number221290
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: