Healthcare Provider Details

I. General information

NPI: 1780429860
Provider Name (Legal Business Name): MAIKEL M LOPEZ LABAEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2024
Last Update Date: 06/29/2024
Certification Date: 06/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 W LOMBARD ST
BALTIMORE MD
21201-1512
US

IV. Provider business mailing address

300 W REDWOOD ST APT 1118
BALTIMORE MD
21201-2359
US

V. Phone/Fax

Practice location:
  • Phone: 410-706-0501
  • Fax:
Mailing address:
  • Phone: 616-482-7012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR264267
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: