MEDICARE: PAOLA MARCELA AMAYA DE LOPEZ MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	35.148627	OH
2	390200000X	Student in an Organized Health Care Education/Training Program
3	2080P0006X	Developmental - Behavioral Pediatrics Physician	35.148627	OH

General Provider Information

NPI Number	:	1053831651
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAOLA MARCELA AMAYA DE LOPEZ MD

Provider Business Mailing Address
First Line	:	3333 BURNET AVE ML 4002
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45229-2545
Country	:	US
Telephone Number	:	513-636-4611
Fax Number	:	513-636-3800

Provider Business Practice Location Address
First Line	:	3333 BURNET AVE ML 4002
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45229-2545
Country	:	US
Telephone Number	:	513-636-4611
Fax Number	:	513-636-3800

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2017
Last Update Date	:	02/16/2024

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