Provider Demographics
NPI:1952355968
Name:LOPEZ, MARIO R (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:R
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MARIO
Other - Middle Name:R
Other - Last Name:LOPEZ-CABRERA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:116-1 CALLE 74
Mailing Address - Street 2:VILLA CAROLINA
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00985-4117
Mailing Address - Country:US
Mailing Address - Phone:787-402-9031
Mailing Address - Fax:866-396-9013
Practice Address - Street 1:116-1 CALLE 74
Practice Address - Street 2:VILLA CAROLINA
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00985-4117
Practice Address - Country:US
Practice Address - Phone:787-402-9031
Practice Address - Fax:866-396-9013
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 75291207RI0200X
PR18378207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR18378OtherMEDICAL LICENSE
FLME 75291OtherME NUMBER
FL259930900Medicaid
FLH19643Medicare UPIN