Provider Demographics
NPI:1942345384
Name:MATEO LOPEZ, MANUEL ESTEBAN SR (11772)
Entity Type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:ESTEBAN
Last Name:MATEO LOPEZ
Suffix:SR
Gender:M
Credentials:11772
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1171
Mailing Address - Street 2:
Mailing Address - City:TOA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00954-1171
Mailing Address - Country:US
Mailing Address - Phone:787-870-5025
Mailing Address - Fax:787-870-5025
Practice Address - Street 1:CALLE LUIS MUNOZ RIVERA
Practice Address - Street 2:NUMERO 16
Practice Address - City:TOA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00954
Practice Address - Country:US
Practice Address - Phone:787-870-5025
Practice Address - Fax:787-870-5025
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11772207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRG42591Medicare UPIN
PR87971Medicare ID - Type UnspecifiedPROVIDER ID