Provider Demographics
NPI:1689663858
Name:COLON LOPEZ, DERICK E (MD)
Entity Type:Individual
Prefix:DR
First Name:DERICK
Middle Name:E
Last Name:COLON LOPEZ
Suffix:
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:BOSQUE SENORIAL
Mailing Address - Street 2:2621 PALMA DE SIERRA
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00728
Mailing Address - Country:US
Mailing Address - Phone:787-677-8824
Mailing Address - Fax:787-290-8866
Practice Address - Street 1:PONCE REHAB - TORRE MEDICA SAN LUCAS
Practice Address - Street 2:909 TITO CASTRO AVE. SUITE 621
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00716
Practice Address - Country:US
Practice Address - Phone:787-290-4466
Practice Address - Fax:787-290-8866
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PR12965208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRG85799Medicare UPIN