Healthcare Provider Details

I. General information

NPI: 1134273394
Provider Name (Legal Business Name): LOURDES S. PENA-DE LA VEGA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 02/18/2021
Certification Date: 02/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

URB ATENAS HERNANDEZ CARRION
MANATI PR
00674
US

IV. Provider business mailing address

PO BOX 407
MANATI PR
00674-0407
US

V. Phone/Fax

Practice location:
  • Phone: 787-854-4120
  • Fax: 787-884-5489
Mailing address:
  • Phone: 787-854-4120
  • Fax: 787-884-5489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number13319
License Number StatePR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: