Provider Demographics
NPI:1295132124
Name:OLMO LOPEZ, MARIANO (MD)
Entity type:Individual
Prefix:
First Name:MARIANO
Middle Name:
Last Name:OLMO LOPEZ
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:BF1 CALLE 22
Mailing Address - Street 2:VILLA UNIVERSITARIA
Mailing Address - City:HUMACAO
Mailing Address - State:PR
Mailing Address - Zip Code:00791-4339
Mailing Address - Country:US
Mailing Address - Phone:787-217-4858
Mailing Address - Fax:
Practice Address - Street 1:BF1 CALLE 22
Practice Address - Street 2:VILLA UNIVERSITARIA
Practice Address - City:HUMACAO
Practice Address - State:PR
Practice Address - Zip Code:00791-4339
Practice Address - Country:US
Practice Address - Phone:787-217-4858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-20
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR18950207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine