Provider Demographics
NPI:1184680480
Name:GRACIA-LOPEZ, SANDRA C (MD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:C
Last Name:GRACIA-LOPEZ
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:URB. PASEO DE LA FUENTE
Mailing Address - Street 2:D-4 CALLE TIVOLI
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-6459
Mailing Address - Country:US
Mailing Address - Phone:787-641-7582
Mailing Address - Fax:787-292-7976
Practice Address - Street 1:AVE. JOSE VAZQUEZ ESQ. DR. TROYER
Practice Address - Street 2:NUCLEAR MEDICINE, MENNONITE GENERAL HOSPITAL
Practice Address - City:AIBONITO
Practice Address - State:PR
Practice Address - Zip Code:00705-1379
Practice Address - Country:US
Practice Address - Phone:787-735-8001
Practice Address - Fax:787-292-7976
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2007-08-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PR7213207R00000X, 207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRE04102Medicare UPIN
PR29256Medicare ID - Type Unspecified