Healthcare Provider Details

I. General information

NPI: 1639660673
Provider Name (Legal Business Name): CAROLINA MAYA LOPERA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2018
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 LLANFAIR RD UNIT 6
ARDMORE PA
19003-2320
US

IV. Provider business mailing address

PO BOX 903 NYU AD SOCIAL SCIENCE DEPARTMENT
NEW YORK NY
10276-0903
US

V. Phone/Fax

Practice location:
  • Phone: 877-295-1705
  • Fax:
Mailing address:
  • Phone: 617-909-4766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number83618
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: