Provider Demographics
NPI:1598897241
Name:LOPEZ PEREZ, ELBA
Entity Type:Individual
Prefix:
First Name:ELBA
Middle Name:
Last Name:LOPEZ PEREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB COLINAS METROPOLITANAS
Mailing Address - Street 2:V4 CALLE MONTE DEL ESTADO
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00969
Mailing Address - Country:US
Mailing Address - Phone:787-474-7346
Mailing Address - Fax:
Practice Address - Street 1:URB COLINAS METROPOLITANAS
Practice Address - Street 2:V4 CALLE MONTE DEL ESTADO
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00969
Practice Address - Country:US
Practice Address - Phone:787-474-7346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2012-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR867133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0053519Medicare PIN