Healthcare Provider Details

I. General information

NPI: 1053831651
Provider Name (Legal Business Name): PAOLA MARCELA AMAYA DE LOPEZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2017
Last Update Date: 02/16/2024
Certification Date: 02/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 BURNET AVE ML 4002
CINCINNATI OH
45229-2545
US

IV. Provider business mailing address

3333 BURNET AVE ML 4002
CINCINNATI OH
45229-2545
US

V. Phone/Fax

Practice location:
  • Phone: 513-636-4611
  • Fax: 513-636-3800
Mailing address:
  • Phone: 513-636-4611
  • Fax: 513-636-3800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.148627
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number35.148627
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: