=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407118862
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GREGG LOPEZ
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2012
-----------------------------------------------------
Last Update Date | 06/12/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20 CEDAR ST
-----------------------------------------------------
City | NEW ROCHELLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10801-5247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-576-5292
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21 E LAKE RD
-----------------------------------------------------
City | NEW FAIRFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06812-2531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 967082001
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------