Healthcare Provider Details

I. General information

NPI: 1386460582
Provider Name (Legal Business Name): MANUEL LOPEZ MD, PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2024
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 EUCLID AVE
CLEVELAND OH
44195-0001
US

IV. Provider business mailing address

10600 CHESTER AVE APT 2101
CLEVELAND OH
44106-0247
US

V. Phone/Fax

Practice location:
  • Phone: 216-938-2844
  • Fax:
Mailing address:
  • Phone: 786-616-2536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number1013958
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: