=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093848129
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUAN LOPEZ BERRIOS M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2007
-----------------------------------------------------
Last Update Date | 06/12/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CENTRO COMERCIAL LOS FLAMBOYANES LOCAL 9 AVE 65 DE INFANTERIA
-----------------------------------------------------
City | RIO PIEDRAS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-767-8208
-----------------------------------------------------
Fax | 787-758-6640
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3314
-----------------------------------------------------
City | CAROLINA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00984-3314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-767-8208
-----------------------------------------------------
Fax | 787-758-6640
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 3912
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------