Provider Demographics
NPI:1154985976
Name:GONZALEZ LOPEZ, OMAR JAVIER (LABOTARORIO CARMAR)
Entity type:Individual
Prefix:
First Name:OMAR
Middle Name:JAVIER
Last Name:GONZALEZ LOPEZ
Suffix:
Gender:M
Credentials:LABOTARORIO CARMAR
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 372140
Mailing Address - Street 2:
Mailing Address - City:CAYEY
Mailing Address - State:PR
Mailing Address - Zip Code:00737-2140
Mailing Address - Country:US
Mailing Address - Phone:787-738-9595
Mailing Address - Fax:787-738-1414
Practice Address - Street 1:54 CALLE CARRION MADURO SUR
Practice Address - Street 2:
Practice Address - City:CAYEY
Practice Address - State:PR
Practice Address - Zip Code:00736-0073
Practice Address - Country:US
Practice Address - Phone:787-738-9595
Practice Address - Fax:787-738-1414
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-26
Last Update Date:2019-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR451291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
1023139052OtherNPI