Provider Demographics
NPI:1235432386
Name:LOPEZ, SERGIO
Entity Type:Individual
Prefix:MR
First Name:SERGIO
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5220 CALLE LORENCITA FERRER
Mailing Address - Street 2:EL TUQUE
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00728-4832
Mailing Address - Country:US
Mailing Address - Phone:787-219-9207
Mailing Address - Fax:
Practice Address - Street 1:COND TABAIBA GDNS
Practice Address - Street 2:AVE HUNGRIA # 276
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00716-1384
Practice Address - Country:US
Practice Address - Phone:787-842-6682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-13
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4761CP3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport