Provider Demographics
NPI:1710669544
Name:LOPEZ VILLANUEVA, BLADYS JOHANNA (MEDICINE DOCTOR)
Entity Type:Individual
Prefix:
First Name:BLADYS
Middle Name:JOHANNA
Last Name:LOPEZ VILLANUEVA
Suffix:
Gender:F
Credentials:MEDICINE DOCTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 3 BOX 9110
Mailing Address - Street 2:
Mailing Address - City:MOCA
Mailing Address - State:PR
Mailing Address - Zip Code:00676-9265
Mailing Address - Country:US
Mailing Address - Phone:787-242-4366
Mailing Address - Fax:
Practice Address - Street 1:CARR 464 KM 2.4
Practice Address - Street 2:BO ACEITUNAS
Practice Address - City:MOCA
Practice Address - State:PR
Practice Address - Zip Code:00676
Practice Address - Country:US
Practice Address - Phone:787-242-4366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-02
Last Update Date:2024-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR390200000X, 261QS1000X
PR23512208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health