Healthcare Provider Details

I. General information

NPI: 1659228195
Provider Name (Legal Business Name): FORTUNATO LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2026
Last Update Date: 03/13/2026
Certification Date: 03/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1051 S A ST
OXNARD CA
93030-7442
US

IV. Provider business mailing address

1051 S A ST
OXNARD CA
93030-7442
US

V. Phone/Fax

Practice location:
  • Phone: 805-385-1501
  • Fax:
Mailing address:
  • Phone: 805-385-1501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: