Provider Demographics
NPI:1629016613
Name:DALIVA, AGNES LOPEZ (MD)
Entity Type:Individual
Prefix:DR
First Name:AGNES
Middle Name:LOPEZ
Last Name:DALIVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:215 NORTH ST STE A
Mailing Address - Street 2:SUITE A PEDIATRICS
Mailing Address - City:ELKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21921-5505
Mailing Address - Country:US
Mailing Address - Phone:410-398-8899
Mailing Address - Fax:410-398-1477
Practice Address - Street 1:215 NORTH ST STE A
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:MD
Practice Address - Zip Code:21921-5505
Practice Address - Country:US
Practice Address - Phone:410-398-8899
Practice Address - Fax:410-398-1477
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD55214208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD698400200Medicaid
MD698400200Medicaid