Provider Demographics
NPI:1114143179
Name:LOPEZ, CARMEN MARIA (OTL)
Entity Type:Individual
Prefix:MRS
First Name:CARMEN
Middle Name:MARIA
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:OTL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 132
Mailing Address - Street 2:
Mailing Address - City:AGUADA
Mailing Address - State:PR
Mailing Address - Zip Code:00602-0132
Mailing Address - Country:US
Mailing Address - Phone:787-344-5637
Mailing Address - Fax:787-868-5709
Practice Address - Street 1:ROAD #2
Practice Address - Street 2:
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00682
Practice Address - Country:US
Practice Address - Phone:787-374-0210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR547174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist