Provider Demographics
NPI:1396727715
Name:LOPEZ PLAZA, ILEANA (MD)
Entity type:Individual
Prefix:DR
First Name:ILEANA
Middle Name:
Last Name:LOPEZ PLAZA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ILEANA
Other - Middle Name:
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:750 WASHINGTON ST #826
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111
Mailing Address - Country:US
Mailing Address - Phone:617-636-5842
Mailing Address - Fax:617-636-3175
Practice Address - Street 1:750 WASHINGTON ST #826
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111
Practice Address - Country:US
Practice Address - Phone:617-636-5842
Practice Address - Fax:617-636-3175
Is Sole Proprietor?:No
Enumeration Date:2005-11-20
Last Update Date:2007-07-31
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2007-07-31
Provider Licenses
StateLicense IDTaxonomies
MA221290207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2075431Medicaid
MAA37261OtherMEDICARE LO
MAA37261OtherMEDICARE LO