Provider Demographics
NPI:1699769778
Name:LOPEZ MONEGRO, RAFAEL (MD)
Entity type:Individual
Prefix:
First Name:RAFAEL
Middle Name:
Last Name:LOPEZ MONEGRO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17A BEECH GROVE ROAD
Mailing Address - Street 2:
Mailing Address - City:HONESDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18431-1445
Mailing Address - Country:US
Mailing Address - Phone:570-253-0800
Mailing Address - Fax:570-253-0800
Practice Address - Street 1:17A BEECH GROVE ROAD
Practice Address - Street 2:
Practice Address - City:HONESDALE
Practice Address - State:PA
Practice Address - Zip Code:18431-1445
Practice Address - Country:US
Practice Address - Phone:570-253-0800
Practice Address - Fax:570-253-0800
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-06
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD046535L208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012909800002Medicaid
PAD7614Medicare UPIN
PA0012909800002Medicaid
PA109403DOLMedicare PIN