Healthcare Provider Details

I. General information

NPI: 1255815593
Provider Name (Legal Business Name): MICHAEL LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2018
Last Update Date: 09/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 LAKE DR
MEDFORD NY
11763-4606
US

IV. Provider business mailing address

403 LAKE DR
MEDFORD NY
11763-4606
US

V. Phone/Fax

Practice location:
  • Phone: 718-578-1375
  • Fax:
Mailing address:
  • Phone: 718-578-1375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: