Healthcare Provider Details

I. General information

NPI: 1508308420
Provider Name (Legal Business Name): SARAH LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2016
Last Update Date: 12/23/2025
Certification Date: 12/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 WILSON TER
GLENDALE CA
91206-4007
US

IV. Provider business mailing address

1509 WILSON TER
GLENDALE CA
91206-4007
US

V. Phone/Fax

Practice location:
  • Phone: 818-409-8000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A15031
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number22710
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number92619
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: