Provider Demographics
NPI:1740491174
Name:LOPEZ, MARIEMMA MAGE (MD)
Entity type:Individual
Prefix:DR
First Name:MARIEMMA
Middle Name:MAGE
Last Name:LOPEZ
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:PO BOX 800250
Mailing Address - Street 2:
Mailing Address - City:COTO LAUREL
Mailing Address - State:PR
Mailing Address - Zip Code:00780-0250
Mailing Address - Country:US
Mailing Address - Phone:787-848-1826
Mailing Address - Fax:787-843-8977
Practice Address - Street 1:COMPLEJO CORRECCIONAL LAS CUCHARAS
Practice Address - Street 2:EL TUQUE
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00732
Practice Address - Country:US
Practice Address - Phone:787-841-8005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR15039208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR15039OtherSTATE LICENSE