Provider Demographics
NPI:1861612038
Name:LOPEZ - SOTO, IRMA E (OD)
Entity type:Individual
Prefix:DR
First Name:IRMA
Middle Name:E
Last Name:LOPEZ - SOTO
Suffix:
Gender:F
Credentials:OD
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 363749
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00936-3749
Mailing Address - Country:US
Mailing Address - Phone:787-565-2155
Mailing Address - Fax:
Practice Address - Street 1:AVE. FRAGOSO #14 VILLA FONTANA
Practice Address - Street 2:
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00983
Practice Address - Country:US
Practice Address - Phone:787-565-2155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR317152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR58127LOOtherTRIPLE-S, INC
PR58127OtherMEDICARE OPTIMO TRIPLE-S
PR58127Medicare ID - Type Unspecified