Healthcare Provider Details

I. General information

NPI: 1336165281
Provider Name (Legal Business Name): DR. CARLOS A LOPEZ DE VICTORIA CABRERA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 CALLE CONCEPCION STE 1
GUAYANILLA PR
00656-1710
US

IV. Provider business mailing address

802 CALLE CAMPECHE
PONCE PR
00717-1770
US

V. Phone/Fax

Practice location:
  • Phone: 787-835-8237
  • Fax: 787-835-8237
Mailing address:
  • Phone: 787-843-6174
  • Fax: 787-843-6174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number11252
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: