Provider Demographics
NPI:1184778466
Name:GOMEZ-HORMAZAGAL, LOPE MANUEL
Entity type:Individual
Prefix:
First Name:LOPE
Middle Name:MANUEL
Last Name:GOMEZ-HORMAZAGAL
Suffix:
Gender:M
Credentials:
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 3762
Mailing Address - Street 2:
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00984-3762
Mailing Address - Country:US
Mailing Address - Phone:787-752-7897
Mailing Address - Fax:
Practice Address - Street 1:AVE ROBERTO SANCHEZ VILELLA, A6 CASTELLANA GARDENS
Practice Address - Street 2:
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00984-0098
Practice Address - Country:US
Practice Address - Phone:787-752-7897
Practice Address - Fax:787-768-0689
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11577208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice