Provider Demographics
NPI:1376528661
Name:LOPEZ, SHEREE L (MD)
Entity Type:Individual
Prefix:
First Name:SHEREE
Middle Name:L
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHEREE
Other - Middle Name:L
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6096 E MAIN ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-4302
Mailing Address - Country:US
Mailing Address - Phone:614-577-0400
Mailing Address - Fax:614-577-0040
Practice Address - Street 1:6096 E MAIN ST
Practice Address - Street 2:SUITE 102
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-4302
Practice Address - Country:US
Practice Address - Phone:614-577-0400
Practice Address - Fax:614-577-0040
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-09
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.080590207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2413052Medicaid
OH4093852Medicare ID - Type Unspecified
OHH176530Medicare PIN