Healthcare Provider Details

I. General information

NPI: 1649664632
Provider Name (Legal Business Name): DON VINCENT VICTOR LOPEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2015
Last Update Date: 06/20/2022
Certification Date: 06/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 DALE RD
MODESTO CA
95356-8627
US

IV. Provider business mailing address

769 COLLINS ST
MANTECA CA
95337-8738
US

V. Phone/Fax

Practice location:
  • Phone: 209-557-1650
  • Fax:
Mailing address:
  • Phone: 209-602-6880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number151854
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: