Provider Demographics
NPI:1760423222
Name:LOPEZ, TANYA I (MD)
Entity Type:Individual
Prefix:MRS
First Name:TANYA
Middle Name:I
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:TANYA
Other - Middle Name:I
Other - Last Name:LOPEZ-SANTIAGO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:AVE. RICARDO SERRANO #15
Mailing Address - Street 2:
Mailing Address - City:SAN SEBASTIAN
Mailing Address - State:PR
Mailing Address - Zip Code:00685
Mailing Address - Country:US
Mailing Address - Phone:787-486-5646
Mailing Address - Fax:787-280-1335
Practice Address - Street 1:126 CALLE PAVIA FERNANDEZ
Practice Address - Street 2:
Practice Address - City:SAN SEBASTIAN
Practice Address - State:PR
Practice Address - Zip Code:00685-2285
Practice Address - Country:US
Practice Address - Phone:787-436-5646
Practice Address - Fax:787-280-1335
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2017-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR15041208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0022039Medicare UPIN
PRH99114Medicare UPIN
PR22039Medicare ID - Type Unspecified