Provider Demographics
NPI:1740722685
Name:LOPEZ, BENJAMIN
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:LOPEZ
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:CARR NO. 2 KM 8.2 BO. JUAN SANCHEZ
Mailing Address - Street 2:ANTIGUO MEPSI CENTER
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00960-7087
Mailing Address - Country:US
Mailing Address - Phone:787-763-7575
Mailing Address - Fax:
Practice Address - Street 1:CARR 2 KM 157
Practice Address - Street 2:BO SABALOS CENTRO MEDICO MAYAGUEZ
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680
Practice Address - Country:US
Practice Address - Phone:787-763-7575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-09
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5686103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist