Provider Demographics
NPI:1003012931
Name:LOPEZ, NICETO (MD)
Entity Type:Individual
Prefix:DR
First Name:NICETO
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3608 LAKESHORE AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94610-1763
Mailing Address - Country:US
Mailing Address - Phone:510-444-4589
Mailing Address - Fax:
Practice Address - Street 1:801 YGNACIO VALLEY RD
Practice Address - Street 2:SUITE 250
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-3871
Practice Address - Country:US
Practice Address - Phone:925-946-1080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA96421208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA96421OtherMECIAL LICENSE