Provider Demographics
NPI:1114935574
Name:LOPEZ, CARLOS G (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:G
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 1:3270 KERNER BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-4840
Mailing Address - Country:US
Mailing Address - Phone:415-473-2377
Mailing Address - Fax:415-473-4113
Practice Address - Street 1:3270 KERNER BLVD
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-4840
Practice Address - Country:US
Practice Address - Phone:415-473-2377
Practice Address - Fax:415-473-4113
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1523172084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3199592Medicaid
MAA30025Medicare ID - Type Unspecified
H12105Medicare UPIN