Provider Demographics
NPI:1114394079
Name:LOPEZ, ANTHONY MICHAEL (LMT)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:MICHAEL
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 SE 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-3797
Mailing Address - Country:US
Mailing Address - Phone:503-310-3087
Mailing Address - Fax:
Practice Address - Street 1:6504 NE SISKIYOU ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-4572
Practice Address - Country:US
Practice Address - Phone:901-409-1352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-27
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21295172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker