Healthcare Provider Details

I. General information

NPI: 1548709546
Provider Name (Legal Business Name): JORGE MANUEL LOPEZ MERINO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2017
Last Update Date: 07/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 ROLAND WAY STE 100
OAKLAND CA
94621-2034
US

IV. Provider business mailing address

401 ROLAND WAY STE 100
OAKLAND CA
94621-2034
US

V. Phone/Fax

Practice location:
  • Phone: 510-746-2800
  • Fax: 510-746-2810
Mailing address:
  • Phone: 510-746-2800
  • Fax: 510-746-2810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: