Healthcare Provider Details

I. General information

NPI: 1083943948
Provider Name (Legal Business Name): MELISSA LOPEZ MEDICAL MT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2009
Last Update Date: 05/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 W MAIN ST
RIPON CA
95366-2424
US

IV. Provider business mailing address

433 OTIS DR
RIPON CA
95366-3337
US

V. Phone/Fax

Practice location:
  • Phone: 209-819-9712
  • Fax:
Mailing address:
  • Phone: 209-819-9712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number08-1005
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: