Provider Demographics
NPI:1316008956
Name:LOPEZ, DORI D (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:DORI
Middle Name:D
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14449 ROSCOE BLVD
Mailing Address - Street 2:
Mailing Address - City:PANORAMA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91402-3012
Mailing Address - Country:US
Mailing Address - Phone:818-894-9582
Mailing Address - Fax:818-894-0391
Practice Address - Street 1:14449 ROSCOE BLVD
Practice Address - Street 2:
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-3012
Practice Address - Country:US
Practice Address - Phone:818-894-9582
Practice Address - Fax:818-894-0391
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACL 664156FC0801X
CASL 2069156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens Fitter
Not Answered156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADX002069FMedicaid