=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730147901
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDWIN LOPEZ-BERNARD MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2006
-----------------------------------------------------
Last Update Date | 03/28/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1401 ATLANTIC AVE
-----------------------------------------------------
City | ATLANTIC CITY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08401-7022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-572-8686
-----------------------------------------------------
Fax | 609-572-6033
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 53 W WHITE HORSE PIKE STE D
-----------------------------------------------------
City | GALLOWAY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08205-9450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-748-2800
-----------------------------------------------------
Fax | 609-748-6721
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | MA07514000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208M00000X
-----------------------------------------------------
Taxonomy Name | Hospitalist Physician
-----------------------------------------------------
License Number | MA07514000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 25MA07514000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------