Provider Demographics
NPI:1255472585
Name:LOPEZ, MARIDELI M (MD)
Entity Type:Individual
Prefix:
First Name:MARIDELI
Middle Name:M
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARIDELI
Other - Middle Name:M
Other - Last Name:LOPEZ VARGAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 176
Mailing Address - Street 2:
Mailing Address - City:MANLIUS
Mailing Address - State:NY
Mailing Address - Zip Code:13104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7270 BUCKLEY RD
Practice Address - Street 2:
Practice Address - City:NORTH SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212
Practice Address - Country:US
Practice Address - Phone:315-452-0485
Practice Address - Fax:315-452-0491
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2157462084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
H31785Medicare UPIN