Healthcare Provider Details

I. General information

NPI: 1992972079
Provider Name (Legal Business Name): CECILIA G. LOPEZ, MD,PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2008
Last Update Date: 05/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 S GENESEE RD
BURTON MI
48519-1420
US

IV. Provider business mailing address

3020 S GENESEE RD
BURTON MI
48519-1420
US

V. Phone/Fax

Practice location:
  • Phone: 810-744-3321
  • Fax: 810-744-2850
Mailing address:
  • Phone: 810-744-3321
  • Fax: 810-744-2850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberCL046551
License Number StateMI

VIII. Authorized Official

Name: OSIE LUZ
Title or Position: OFFICE MANAGER
Credential:
Phone: 810-744-3321