Provider Demographics
NPI:1003811191
Name:LOPEZ, HENRY AGUSTIN (OD)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:AGUSTIN
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 D. W. HWY
Mailing Address - Street 2:
Mailing Address - City:MERRIMACK
Mailing Address - State:NH
Mailing Address - Zip Code:03054-4169
Mailing Address - Country:US
Mailing Address - Phone:603-424-6500
Mailing Address - Fax:603-423-9894
Practice Address - Street 1:5 COLISEUM AVE
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03063-3292
Practice Address - Country:US
Practice Address - Phone:603-882-9800
Practice Address - Fax:603-882-0556
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0544152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30010494Medicaid
NH30010494Medicaid
RE0787Medicare ID - Type Unspecified