Provider Demographics
NPI:1568433852
Name:LOPEZ-DIAZ, MIGUEL A (MD)
Entity Type:Individual
Prefix:DR
First Name:MIGUEL
Middle Name:A
Last Name:LOPEZ-DIAZ
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 1:243 CALLE PARIS
Mailing Address - Street 2:PMB 1689
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00917-3632
Mailing Address - Country:US
Mailing Address - Phone:787-728-5967
Mailing Address - Fax:787-728-5967
Practice Address - Street 1:1801 AVE PONCE DE LEON
Practice Address - Street 2:SANTURCE MEDICAL MALL, OFICE 406
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00909-1900
Practice Address - Country:US
Practice Address - Phone:787-728-5967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5779207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRD08322Medicare UPIN
PR0025332Medicare ID - Type Unspecified