MEDICARE: MARK T LOPEZ O.D.P.C.

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	152W00000X	Optometrist	CT856	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	090000856CT01	OTHER	CT	BC/BS
3	1487648051	OTHER	CT	VSP VISION SERVICE PLAN
4	0V2229	OTHER	CT	HEALTHNET

General Provider Information

NPI Number	:	1487648051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK T LOPEZ O.D.P.C.

Provider Business Mailing Address
First Line	:	1026 LONG COVE RD
Second Line	:
City	:	GALES FERRY
State	:	CT
Zip	:	06335-1812
Country	:	US
Telephone Number	:	860-464-6060
Fax Number	:	860-464-7013

Provider Business Practice Location Address
First Line	:	1026 LONG COVE RD
Second Line	:
City	:	GALES FERRY
State	:	CT
Zip	:	06335-1812
Country	:	US
Telephone Number	:	860-464-6060
Fax Number	:	860-464-7013

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

Provider Enumeration Date	:	09/09/2005
Last Update Date	:	02/23/2010

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Directions to “ MARK T LOPEZ O.D.P.C.” Practice Location

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