Provider Demographics
NPI:1447316393
Name:BENITEZ LOPEZ, WANDA I (MD)
Entity type:Individual
Prefix:DR
First Name:WANDA
Middle Name:I
Last Name:BENITEZ LOPEZ
Suffix:
Gender:F
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:QUINTAS DE SANTA MARIA
Mailing Address - Street 2:715
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00682-7496
Mailing Address - Country:US
Mailing Address - Phone:787-265-2471
Mailing Address - Fax:
Practice Address - Street 1:QUINTAS DE SANTA MARIA
Practice Address - Street 2:715
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00682-7496
Practice Address - Country:US
Practice Address - Phone:787-265-2471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR68632085R0202X
MOR6E722085R0202X
ARR38102085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
89084OtherSSS
89084OtherSSS