MEDICARE: R ROLAND LOPEZ, M.D., INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332900000X	Non-Pharmacy Dispensing Site	G47742	CA

General Provider Information

NPI Number	:	1982083150
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	R ROLAND LOPEZ, M.D., INC.

Provider Business Mailing Address
First Line	:	2980 N BEVERLY GLEN CIR
Second Line	:	SUITE 100
City	:	LOS ANGELES
State	:	CA
Zip	:	90077-1726
Country	:	US
Telephone Number	:	310-943-4180
Fax Number	:	888-431-8819

Provider Business Practice Location Address
First Line	:	1535 S D ST
Second Line	:	SUITE 240
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92408-3253
Country	:	US
Telephone Number	:	714-963-9595
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	RAYMOND ROLAND LOPEZ
Credential	:	M.D.
Telephone Number	:	714-963-9595

Provider Enumeration Date	:	05/21/2015
Last Update Date	:	10/19/2015

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