Provider Demographics
NPI:1801894787
Name:LOPEZ-MARRERO, AGUSTIN (MD)
Entity type:Individual
Prefix:DR
First Name:AGUSTIN
Middle Name:
Last Name:LOPEZ-MARRERO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:AGUSTIN
Other - Middle Name:
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:600 PINERO AVENUE
Mailing Address - Street 2:SUITE 1701
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00918-4178
Mailing Address - Country:US
Mailing Address - Phone:787-309-1713
Mailing Address - Fax:
Practice Address - Street 1:1511 AVE PONCE DE LEON STE 3
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00909-5001
Practice Address - Country:US
Practice Address - Phone:787-339-2639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13386207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRH85848Medicare UPIN
PR2-1551Medicare ID - Type Unspecified