MEDICARE: CAROLYN CATHERINE LOPEZ MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	036-059398	IL

General Provider Information

NPI Number	:	1053457440
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROLYN CATHERINE LOPEZ MD

Provider Business Mailing Address
First Line	:	1276 N. CLYBOURN
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60610-2089
Country	:	US
Telephone Number	:	312-337-1073
Fax Number	:

Provider Business Practice Location Address
First Line	:	2906 W WILSON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-3727
Country	:	US
Telephone Number	:	773-539-6863
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/30/2007
Last Update Date	:	02/03/2010

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