Healthcare Provider Details

I. General information

NPI: 1356139083
Provider Name (Legal Business Name): IAN OLMEDA LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2025
Last Update Date: 04/30/2025
Certification Date: 04/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 CALLE CASIA
SAN JUAN PR
00921-3201
US

IV. Provider business mailing address

7 CALLE TAINO
VEGA BAJA PR
00693-3617
US

V. Phone/Fax

Practice location:
  • Phone: 787-641-7582
  • Fax:
Mailing address:
  • Phone: 787-460-6012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: