Provider Demographics
NPI:1043260813
Name:LOPEZ-IRIZARRY, KENNICE M (MD)
Entity Type:Individual
Prefix:
First Name:KENNICE
Middle Name:M
Last Name:LOPEZ-IRIZARRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 3 BOX 53099
Mailing Address - Street 2:
Mailing Address - City:TOA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00953-6502
Mailing Address - Country:US
Mailing Address - Phone:787-200-5739
Mailing Address - Fax:
Practice Address - Street 1:2003 AVE BORINQUEN
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00915-3814
Practice Address - Country:US
Practice Address - Phone:787-268-4171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR15487207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I19118Medicare UPIN
15487Medicare ID - Type Unspecified