Healthcare Provider Details

I. General information

NPI: 1366425977
Provider Name (Legal Business Name): LIDY LOPEZ M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/29/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR 36 BOX 6145 CAMINO DR. JULIA #146
SAN JUAN PR
00926-9500
US

IV. Provider business mailing address

RR 36 BOX 6145
SAN JUAN PR
00926-9500
US

V. Phone/Fax

Practice location:
  • Phone: 787-760-2060
  • Fax: 787-748-0498
Mailing address:
  • Phone: 787-760-2060
  • Fax: 787-748-0498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4952
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: