Provider Demographics
NPI:1336165281
Name:LOPEZ DE VICTORIA CABRERA, CARLOS A
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:A
Last Name:LOPEZ DE VICTORIA CABRERA
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 1:802 CALLE CAMPECHE
Mailing Address - Street 2:
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00717-1770
Mailing Address - Country:US
Mailing Address - Phone:787-843-6174
Mailing Address - Fax:787-843-6174
Practice Address - Street 1:10 CALLE CONCEPCION STE 1
Practice Address - Street 2:
Practice Address - City:GUAYANILLA
Practice Address - State:PR
Practice Address - Zip Code:00656-1710
Practice Address - Country:US
Practice Address - Phone:787-835-8237
Practice Address - Fax:787-835-8237
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11252208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR119-11752OtherGLOBAL HEATH PLAN
PR3202OtherPMC-MEDICARE
PR84088LOMedicaid
PR3202OtherPMC-MEDICARE
PR84088LOMedicaid