Healthcare Provider Details

I. General information

NPI: 1003811191
Provider Name (Legal Business Name): HENRY AGUSTIN LOPEZ O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 COLISEUM AVE
NASHUA NH
03063-3292
US

IV. Provider business mailing address

380 D. W. HWY
MERRIMACK NH
03054-4169
US

V. Phone/Fax

Practice location:
  • Phone: 603-882-9800
  • Fax: 603-882-0556
Mailing address:
  • Phone: 603-424-6500
  • Fax: 603-423-9894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0544
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: