Provider Demographics
NPI:1083943948
Name:LOPEZ, MELISSA (MEDICAL MT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MEDICAL MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 OTIS DR
Mailing Address - Street 2:
Mailing Address - City:RIPON
Mailing Address - State:CA
Mailing Address - Zip Code:95366-3337
Mailing Address - Country:US
Mailing Address - Phone:209-819-9712
Mailing Address - Fax:
Practice Address - Street 1:318 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RIPON
Practice Address - State:CA
Practice Address - Zip Code:95366-2424
Practice Address - Country:US
Practice Address - Phone:209-819-9712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-23
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA08-1005174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist