Healthcare Provider Details

I. General information

NPI: 1962908111
Provider Name (Legal Business Name): BLAKE LOPEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2018
Last Update Date: 04/04/2022
Certification Date: 03/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 GROSSMONT CENTER DR
LA MESA CA
91942-3019
US

IV. Provider business mailing address

50 W 90TH ST APT 6B
NEW YORK NY
10024-1564
US

V. Phone/Fax

Practice location:
  • Phone: 619-465-0711
  • Fax:
Mailing address:
  • Phone: 619-243-4901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA177065
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: