Provider Demographics
NPI:1053307470
Name:LOPEZ, MARVIN J (MD)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:J
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:77 WARREN ST
Mailing Address - Street 2:RM 339
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135
Mailing Address - Country:US
Mailing Address - Phone:617-562-5359
Mailing Address - Fax:617-562-5415
Practice Address - Street 1:11 NEVINS ST
Practice Address - Street 2:STE 201
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135
Practice Address - Country:US
Practice Address - Phone:617-789-2442
Practice Address - Fax:617-789-4207
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA76718208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3102076Medicaid
MA3102076Medicaid
A12221Medicare UPIN