Healthcare Provider Details

I. General information

NPI: 1780618728
Provider Name (Legal Business Name): MICHELLE A LOPEZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 03/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1504 S COMMERCIAL ST
NEENAH WI
54956-4802
US

IV. Provider business mailing address

PO BOX 8003
APPLETON WI
54912-8003
US

V. Phone/Fax

Practice location:
  • Phone: 920-729-6088
  • Fax:
Mailing address:
  • Phone: 920-996-3298
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number43331-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: