Provider Demographics
NPI:1164920807
Name:LOPEZ, EDWIN BANNACEK (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:BANNACEK
Last Name:LOPEZ
Suffix:
Gender:M
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:PO BOX 13
Mailing Address - Street 2:
Mailing Address - City:GUAYAMA
Mailing Address - State:PR
Mailing Address - Zip Code:00785-0013
Mailing Address - Country:US
Mailing Address - Phone:787-409-6657
Mailing Address - Fax:
Practice Address - Street 1:CALLE FRANCISCO G BRUNO #48 OESTE ESQUINA SAN ANTONIO
Practice Address - Street 2:
Practice Address - City:GUAYAMA
Practice Address - State:PR
Practice Address - Zip Code:00784-0078
Practice Address - Country:US
Practice Address - Phone:787-409-6657
Practice Address - Fax:787-409-6657
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-29
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR19831208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice