Healthcare Provider Details

I. General information

NPI: 1417868381
Provider Name (Legal Business Name): MARIO GABRIEL LOPEZ DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 N MICHILLINDA AVE APT 202
PASADENA CA
91107-1922
US

IV. Provider business mailing address

1015 N MICHILLINDA AVE APT 202
PASADENA CA
91107-1922
US

V. Phone/Fax

Practice location:
  • Phone: 909-282-8376
  • Fax:
Mailing address:
  • Phone: 909-282-8376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT307627
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: