Provider Demographics
NPI:1053457440
Name:LOPEZ, CAROLYN CATHERINE (MD)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:CATHERINE
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1276 N. CLYBOURN
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-2089
Mailing Address - Country:US
Mailing Address - Phone:312-337-1073
Mailing Address - Fax:
Practice Address - Street 1:2906 W WILSON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3727
Practice Address - Country:US
Practice Address - Phone:773-539-6863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-059398207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL187543Medicare UPIN