=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710241013
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL LOPEZ M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2012
-----------------------------------------------------
Last Update Date | 05/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 771 OLD NORCROSS RD STE 110
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30046-4977
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-253-2593
-----------------------------------------------------
Fax | 770-488-9408
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2970 BRANDYWINE RD # 125
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30341-5528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-253-2593
-----------------------------------------------------
Fax | 770-488-9408
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080P0202X
-----------------------------------------------------
Taxonomy Name | Pediatric Cardiology Physician
-----------------------------------------------------
License Number | ME120671
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RC0001X
-----------------------------------------------------
Taxonomy Name | Clinical Cardiac Electrophysiology Physician
-----------------------------------------------------
License Number | 98904
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------