Provider Demographics
NPI:1760683940
Name:LOPEZ BEAUCHAMP, VANESSA (MD)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:LOPEZ BEAUCHAMP
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:WINSTON CHURCHILL AVE #138
Mailing Address - Street 2:PMB 791
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-6023
Mailing Address - Country:US
Mailing Address - Phone:787-415-8826
Mailing Address - Fax:
Practice Address - Street 1:AVE JESUS T PINERO 1250
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00922
Practice Address - Country:US
Practice Address - Phone:787-781-2565
Practice Address - Fax:787-792-8524
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009010054207W00000X
PR16609208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO152360089Medicare UPIN