Healthcare Provider Details

I. General information

NPI: 1417967308
Provider Name (Legal Business Name): MARCOS ANTONIO LOPEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9005 W CERMAK RD
NORTH RIVERSIDE IL
60546-1017
US

IV. Provider business mailing address

9005 W CERMAK RD
NORTH RIVERSIDE IL
60546-1017
US

V. Phone/Fax

Practice location:
  • Phone: 708-442-8010
  • Fax: 708-442-8009
Mailing address:
  • Phone: 708-442-8010
  • Fax: 708-442-8009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036092620
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: