Provider Demographics
NPI:1538563952
Name:LOPEZ, MYRA ZORAIDA ESTABILLO
Entity type:Individual
Prefix:
First Name:MYRA ZORAIDA
Middle Name:ESTABILLO
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MYRA ZORAIDA
Other - Middle Name:BERNARDO
Other - Last Name:ESTABILLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:716 RAMSEY CT APT 103
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-2836
Mailing Address - Country:US
Mailing Address - Phone:443-736-6710
Mailing Address - Fax:
Practice Address - Street 1:716 RAMSEY CT APT 103
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-2836
Practice Address - Country:US
Practice Address - Phone:443-736-6710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-14
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23210225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist