Healthcare Provider Details

I. General information

NPI: 1700400777
Provider Name (Legal Business Name): RYAN DAVID LOPEZ OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2020
Last Update Date: 06/04/2020
Certification Date: 06/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16816 CLARK AVE
BELLFLOWER CA
90706-5702
US

IV. Provider business mailing address

11725 SAMOLINE AVE
DOWNEY CA
90241-4715
US

V. Phone/Fax

Practice location:
  • Phone: 562-925-6591
  • Fax:
Mailing address:
  • Phone: 562-659-3228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number34509
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: