Provider Demographics
NPI:1164853248
Name:LOPEZ, JOMARA
Entity Type:Individual
Prefix:
First Name:JOMARA
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5032 31ST AVE
Mailing Address - Street 2:APT. 4D
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-1361
Mailing Address - Country:US
Mailing Address - Phone:718-853-9700
Mailing Address - Fax:347-390-8214
Practice Address - Street 1:5032 31ST AVE
Practice Address - Street 2:APT. 4D
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-1361
Practice Address - Country:US
Practice Address - Phone:718-853-9700
Practice Address - Fax:347-390-8214
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-27
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY233483102171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator