Provider Demographics
NPI:1346281813
Name:LOPEZ, ERNESTO M (MD)
Entity Type:Individual
Prefix:
First Name:ERNESTO
Middle Name:M
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 1:4290 BROADWAY
Mailing Address - Street 2:SUITE 2-S
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-3732
Mailing Address - Country:US
Mailing Address - Phone:212-781-5075
Mailing Address - Fax:212-781-4823
Practice Address - Street 1:4290 BROADWAY
Practice Address - Street 2:SUITE 2-S
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-3732
Practice Address - Country:US
Practice Address - Phone:212-781-5075
Practice Address - Fax:212-781-4823
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY123637-1207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00232531Medicaid
NY00232531Medicaid
NY00232531Medicaid