Healthcare Provider Details

I. General information

NPI: 1639584741
Provider Name (Legal Business Name): JOHANA V. BETANCES LOPEZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2014
Last Update Date: 10/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CENTRO MEDICO BO. MONACILLOS CARR. 22
SAN JUAN PR
00935-0001
US

IV. Provider business mailing address

CENTRO MEDICO BO. MONACILLOS CARR. 22
SAN JUAN PR
00935-0001
US

V. Phone/Fax

Practice location:
  • Phone: 787-777-3535
  • Fax:
Mailing address:
  • Phone: 787-777-3535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number19694
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: