Provider Demographics
NPI:1821732843
Name:DERICK E. COLON LOPEZ
Entity Type:Organization
Organization Name:DERICK E. COLON LOPEZ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DERICK
Authorized Official - Middle Name:ENRIQUE
Authorized Official - Last Name:COLON LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-290-4466
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:787-290-4466
Mailing Address - Fax:787-290-8866
Practice Address - Street 1: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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-26
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation