Provider Demographics
NPI:1134273394
Name:PENA-DE LA VEGA, LOURDES S (MD)
Entity type:Individual
Prefix:
First Name:LOURDES
Middle Name:S
Last Name:PENA-DE LA VEGA
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:PO BOX 407
Mailing Address - Street 2:
Mailing Address - City:MANATI
Mailing Address - State:PR
Mailing Address - Zip Code:00674-0407
Mailing Address - Country:US
Mailing Address - Phone:787-854-4120
Mailing Address - Fax:787-884-5489
Practice Address - Street 1:URB ATENAS HERNANDEZ CARRION
Practice Address - Street 2:
Practice Address - City:MANATI
Practice Address - State:PR
Practice Address - Zip Code:00674
Practice Address - Country:US
Practice Address - Phone:787-854-4120
Practice Address - Fax:787-884-5489
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13319207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H37950Medicare UPIN