Healthcare Provider Details

I. General information

NPI: 1033481593
Provider Name (Legal Business Name): MATTHEW JOSEPH LOPEZ MED STUDENT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2012
Last Update Date: 06/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4610 X ST
SACRAMENTO CA
95817-2200
US

IV. Provider business mailing address

2100 POWELL ST STE 900
EMERYVILLE CA
94608-1844
US

V. Phone/Fax

Practice location:
  • Phone: 916-762-7911
  • Fax:
Mailing address:
  • Phone: 510-851-7446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA148590
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: