Provider Demographics
NPI:1063492536
Name:LOPEZ, ANTONIO DS (MD)
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:DS
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 1:52 WASHINGTON AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-1724
Mailing Address - Country:US
Mailing Address - Phone:203-672-2800
Mailing Address - Fax:203-672-2801
Practice Address - Street 1:52 WASHINGTON AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-1724
Practice Address - Country:US
Practice Address - Phone:203-672-2800
Practice Address - Fax:203-672-2801
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT036552174400000X, 207RE0101X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004212932Medicaid
CTG66990Medicare UPIN
CT110007984Medicare ID - Type UnspecifiedMEDICARE