Provider Demographics
NPI:1780687962
Name:LOPEZ VERGE, RAUL E (MD)
Entity Type:Individual
Prefix:DR
First Name:RAUL
Middle Name:E
Last Name:LOPEZ VERGE
Suffix:
Gender:M
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:PO BOX 864
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:PR
Mailing Address - Zip Code:00690-0864
Mailing Address - Country:US
Mailing Address - Phone:787-882-0592
Mailing Address - Fax:787-882-0562
Practice Address - Street 1:0.3 CARR 110
Practice Address - Street 2:CEIBA BAJA
Practice Address - City:AGUADILLA
Practice Address - State:PR
Practice Address - Zip Code:00603
Practice Address - Country:US
Practice Address - Phone:787-882-0592
Practice Address - Fax:787-882-0562
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR14569174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR263896563Medicaid
PR0021469Medicare ID - Type UnspecifiedMEDICARE PROVIDER #