Healthcare Provider Details

I. General information

NPI: 1295132124
Provider Name (Legal Business Name): MARIANO OLMO LOPEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2014
Last Update Date: 02/21/2020
Certification Date: 02/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BF1 CALLE 22 VILLA UNIVERSITARIA
HUMACAO PR
00791-4339
US

IV. Provider business mailing address

BF1 CALLE 22 VILLA UNIVERSITARIA
HUMACAO PR
00791-4339
US

V. Phone/Fax

Practice location:
  • Phone: 787-217-4858
  • Fax:
Mailing address:
  • Phone: 787-217-4858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number18950
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: