Provider Demographics
NPI:1861542508
Name:LOPEZ VAZQUEZ, MYRTA (MD GEN)
Entity type:Individual
Prefix:MRS
First Name:MYRTA
Middle Name:
Last Name:LOPEZ VAZQUEZ
Suffix:
Gender:F
Credentials:MD GEN
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 9091
Mailing Address - Street 2:COTTO STATION
Mailing Address - City:ARECIBO
Mailing Address - State:PR
Mailing Address - Zip Code:00613
Mailing Address - Country:US
Mailing Address - Phone:787-879-1585
Mailing Address - Fax:787-879-4315
Practice Address - Street 1:URB VILLA LOS SANTOS
Practice Address - Street 2:CALLE 16 V1
Practice Address - City:ARECIBO
Practice Address - State:PR
Practice Address - Zip Code:00612
Practice Address - Country:US
Practice Address - Phone:787-879-1585
Practice Address - Fax:787-879-4315
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR9531208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRG02899Medicare UPIN