Provider Demographics
NPI:1326290958
Name:LOPEZ, MICHAEL JONATHON (PTA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JONATHON
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 ORCHARD DR
Mailing Address - Street 2:
Mailing Address - City:ELIDA
Mailing Address - State:OH
Mailing Address - Zip Code:45807-1081
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:116 ORCHARD DR
Practice Address - Street 2:
Practice Address - City:ELIDA
Practice Address - State:OH
Practice Address - Zip Code:45807-1081
Practice Address - Country:US
Practice Address - Phone:937-399-9217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-14
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA.07095174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist