Provider Demographics
NPI:1326218223
Name:HERNANDEZ LOPEZ, ILLIAD E (T M)
Entity Type:Individual
Prefix:
First Name:ILLIAD
Middle Name:E
Last Name:HERNANDEZ LOPEZ
Suffix:
Gender:F
Credentials:T M
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 357
Mailing Address - Street 2:
Mailing Address - City:MOCA
Mailing Address - State:PR
Mailing Address - Zip Code:00676
Mailing Address - Country:US
Mailing Address - Phone:787-877-1895
Mailing Address - Fax:787-877-1895
Practice Address - Street 1:85 CALLE DON CHEMARY
Practice Address - Street 2:
Practice Address - City:MOCA
Practice Address - State:PR
Practice Address - Zip Code:00676
Practice Address - Country:US
Practice Address - Phone:787-877-1895
Practice Address - Fax:787-877-1895
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-06
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR610246QM0706X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0030836Medicare PIN