Provider Demographics
NPI:1740387190
Name:LOPEZ-PENA, MARICARMEN (MD)
Entity type:Individual
Prefix:DR
First Name:MARICARMEN
Middle Name:
Last Name:LOPEZ-PENA
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 1:22 NEW SCOTLAND AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-3795
Mailing Address - Country:US
Mailing Address - Phone:518-262-7337
Mailing Address - Fax:518-262-0283
Practice Address - Street 1:22 NEW SCOTLAND AVE # MC-88
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3795
Practice Address - Country:US
Practice Address - Phone:518-262-5332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2921722080P0216X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0216XAllopathic & Osteopathic PhysiciansPediatricsPediatric Rheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H4661Medicare UPIN