Healthcare Provider Details

I. General information

NPI: 1932107562
Provider Name (Legal Business Name): NICHOLAS M LOPEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6855 SPRING VALLEY DR STE 120
HOLLAND OH
43528-8039
US

IV. Provider business mailing address

4235 SECOR RD
TOLEDO OH
43623-4231
US

V. Phone/Fax

Practice location:
  • Phone: 419-865-3111
  • Fax:
Mailing address:
  • Phone: 419-865-3111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35041209L
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: